Health inspection·January 13, 2026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that two of four sampled residents (Resident 1 and 2) who were fall risk, were provided with ordered and care-planned safety devices to reduce the risk of accidents. For Resident 1, the facility failed to ensure Resident 1's 's wheelchair had footrests and alarm as ordered by physician, and for Resident 2, the facility failed to ensure Resident 2 had footrests applied as recommended by Physical Therapy. These deficient practices had the potential to result in injury for Resident 1 and 2, during wheelchair transfer by facility staff.1.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of degeneration of brain, dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), weakness, and bilateral osteoarthritis (OA- is the most common form of arthritis, a degenerative joint disease where the protective cartilage cushioning the ends of bones wears down over time, leading to pain, stiffness, swelling, and reduced mobility as bones start rubbing together) of knees.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 12/17/2025, the MDS indicated Resident 1 had severely impaired cognitive (ability to think, remember and reason) skills for daily decision making. The MDS indicated Resident 1 required maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for oral hygiene, toileting, upper and lower body dressing, putting on footwear, personal hygiene, toilet transfer, shower transfer, and walking 10 feet. The MDS indicated Resident 1 required partial assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for eating, roll left and right, sit to lying, lying to sitting, sit to stand, and chair to bed-chair transfer.During a review of Resident 1's Comprehensive Care Plan (CP- a personalized document that outlines a resident's needs, goals, and the specific services required to achieve them, ensuring consistent and holistic care), dated 12/24/2025 , indicated Resident 1 required maximal assistance while using locomotion (refers to a person's ability to move from one place to another like walking, transferring from bed to chair, using a wheelchair) on and off the unit.During a review of Resident 1's Order Summary, dated 10/23/20205, indicated Resident 1 may have wheelchair alarm while up in wheelchair to alert staff when resident is trying to get up unassisted. The Order Summary dated 9/25/2025 indicated a floor mat should be placed on right side of Resident 1's bed to prevent injury for any fall.2.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of weakness, osteoporosis (bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes. This can lead to a decrease in bone strength that can increase the risk of broken bones), and Alzheimer's disease (a progressive brain disorder, the most common type of dementia, that slowly destroys memory, thinking, and Page 1 of 2 055157 055157 01/13/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reasoning skills, eventually impairing the ability to perform daily activities).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognitive (ability to think, remember and reason) skills for daily decision making. The MDS indicated Resident 2 required maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toileting, showering, upper and lower body dressing, putting on footwear, sit to stand, chair/bed transfer, and toilet transfer. The MDS indicated Resident 2 required partial assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for oral hygiene, personal hygiene, roll left and right, sit to lying, lying to sitting, and required supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for eating.During a review of Resident 2's Comprehensive Care Plan, dated 1/7/2026 , indicated Resident 1 required maximal assistance while using locomotion on and off the unit.During a concurrent observation and interview on 1/13/2026 at 11AM with the Activity Assistant, in the activity room, Resident 1 and Resident 2 sat down in their wheelchairs without footrest around a round table. The activity assistant offered to transfer Resident 2 back to her room so that she could talk in private with the surveyor. The activity assistant stated he had not been trained in transferring residents on wheelchairs and did not know why they didn't have footrest.During a concurrent observation and interview on 1/13/2026 at 11:14 AM with Certified Nursing Assistant 2 (CNA2) in Resident 1's room, CNA2 stated the wheelchair did not have footrests, no wheelchair alarm, and there was no floor mat in the room. CNA2 stated Maintenance should have the foot rests placed on the wheelchair and began searching the closets for the footrests.During an interview on 1/13/2026 at 11:49 AM with the Quality Assurance (QA) nurse, the QA nurse mentioned that if a resident can move themselves using their feet while in a wheelchair, footrests are not attached. However, if the residents have hemiplegia, weakness, or are at risk of falling, the footrests should be used, especially if advised by physical therapy staff.During an interview on 1/13/2026 at 11:53 AM with the Physical Therapy Director (PTD), the PTD mentioned that residents who need a footrest on their wheelchair are typically those with weakness, depending on their history. The PTD noted that Resident 2 should have a footrest since she recently returned from the hospital, has weakness, and attends therapy three times a week. Regarding Resident 1, the PTD said he provided a footrest for her wheelchair but did not actually recommend it.During an interview on 1/13/2026 at 12 PM with the Minimum Data Set (MDS) Nurse, the MDS Nurse stated Resident 1 was at high risk for falls, required maximal assist which would indicate to a staff member they should be doing maximal assist for wheelchair transfers, and a footrest should be in place. The MDS Nurse stated Resident 2 had a low fall risk, however due to her recent hospitalization she was weaker than usual and if these residents had any weakness to assist in lifting their feet during a wheelchair transfer, their feet could drag and result in injury. The MDS Nurse stated if residents have orders for alarms and floor mats, these should be implemented to ensure resident safety and failure to do so would impact resident safety negatively.During a review of the facility's policy and procedures (P&P) titled Managing Falls and Fall Risk, dated 11/21/2025, the P&P indicated staff will identify appropriate interventions to reduce the risk of falls with the input of the Attending Physician. In conjunction with the Attending Physician, staff will identify and implement relevant interventions to minimize serious consequences of falling. 055157 Page 2 of 2