Health inspection·February 6, 2026

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform one of five sampled residents (Resident 54) in advance of the risks and benefits of a psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior). This failure violated Resident 54's right to make an informed decision regarding the use of a psychoactive medication. Findings:During a review of Resident 54's admission Record, the admission Record indicated the facility originally admitted Resident 54 on 4/9/2024 and readmitted Resident 54 on 1/14/2026 with diagnoses that included other seizures (involuntary events caused by brain electrical changes, stress, or trauma rather than epilepsy [a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures]), other muscle spasm (painful contractions and tightening of your muscles), hepatic encephalopathy (decline in brain function caused by severe liver disease) and other sequelae of cerebral infraction (long-term, lasting complications or physical/mental issues that remain after a stroke, loss of blood flow to a part of the brain). During a review of Resident 54's Progress Note dated 5/13/2024, the Progress Note indicated Resident 54's Family Member (FAM 1) was the first emergency contact and would assist with decision-making. During a review of Resident 54's Minimum Data Set (MDS - a resident assessment tool) dated 1/2/2026, the MDS indicated Resident 54 had the ability to make himself understood and had the ability to understand others. During a review of Resident 54's Progress Note dated 1/9/2026 at 6:50 PM, the Progress Note indicated Resident 54 had continuous body muscle spasms (involuntary contraction [increase in the tension or a decrease in the length] of a muscle) and was given diazepam (medication to treat a range of conditions including muscle spasms and seizures) two milligrams (mgs, a unit of mass) as needed for tremors (involuntary shaking or trembling). During a review of Resident 54's Order Summary Report dated 2/5/2026, the Order Summary Report indicated Resident 54 had a telephone order for diazepam two mgs orally every eight hours as needed for muscle spasm dated and started on 1/14/2026. During a review of Resident 54's physical and electronic medical record (EMR - a digital, computer-based version of a patient's paper chart), Resident 54's History and Physical (H&P), physician progress notes, consent for diazepam, and documentation of Resident 54's capacity (ability) to understand and make decisions could not be located. During a concurrent interview and record review on 2/5/2026 at 2:20 PM with Licensed Vocational Nurse 1 (LVN 1), Resident 54's informed consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure) dated 1/14/2026 for diazepam was reviewed. LVN 1 stated the informed consent indicated Medical Doctor 1 (MD 1) did not sign the informed consent. LVN1 stated the informed consent indicated Resident 54 and Resident 54's representative's name and date were blank and not signed. LVN 1 stated the informed consent was not signed by Resident 54's physician or by Resident 54's responsible party. During a concurrent interview and record review on 2/5/2026 at 2:25 PM with Registered Nurse 2 (RN 2), Resident Residents Affected - Few Page 1 of 33 055157 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 54's informed consent dated 1/14/2026 for diazepam was reviewed. RN 2 stated the informed consent had not been signed by the prescriber (MD1) or by Resident 54's representative (FAM 1). RN 2 stated Resident 54 and FAM1 needed to be informed regarding the risks and benefits of taking diazepam. During an interview on 2/5/2026 at 2:56 PM with the facility's Medical Records (MR), the MR stated she (MR) could not find any consents for Resident 54 for the use of diazepam. The MR stated Resident 54's physician did not do a history and physical since Resident 54 was readmitted on [DATE]. During an interview with Resident 54's FAM 1 on 2/5/2026 at 3:20 PM, FAM 1 stated that no one from the facility talked with her (FAM1) regarding Resident 54's informed consent for the use of diazepam. During an interview on 2/5/2026 at 3:26 an attempt was made to speak with Resident 54 about the informed consent for medications. Resident 54 was not able to participate in the interview. During a concurrent interview and record review on 2/5/2026 at 4:01 PM with the facility's Director of Nursing (DON), the facility's policy and procedure (P&P) titled Resident Rights, dated 1/2025 was reviewed. The DON stated the P&P indicated All residents have rights guaranteed to them under Federal and State laws and regulations. The P&P indicated residents (in general) had the right to be informed/make treatment decisions. The DON stated Resident 54's physician should have gotten informed consent from Resident 54 or Resident 54's representative before giving Resident 54 diazepam. The DON stated the facility did not follow their Resident Rights policy. 055157 Page 2 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide reasonable accommodation to meet resident needs for three of three sampled residents (Residents 12, 53, and 74). By failing to:1.Ensure Resident 12 and Resident 74 were provided with a communication board (a bedside tool used to bridge gaps in verbal communication for residents who speak another language or have limited speech. These boards feature pictures, letters, or words representing basic needs, pain levels, and feelings, allowing residents to point to express themselves) in the language that Resident 12 and Resident 74 were able to understand.2. Provide Resident 53 who had limited use of hands with an appropriate call light (a device with a button or touchpad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance). These failures had the potential to result in a delay in the delivery of necessary care to Residents 12, 53, and 74.Findings: Residents Affected - Few 1.During a review of Resident 12's admission Record, the admission Record indicated the facility re-admitted the resident on 12/11/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated period of emotional highs). During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool) dated 1/5/2026, the MDS indicated the resident's preferred language was Korean. The MDS indicated Resident 12 had severely impaired cognition (impairment in the ability to think, understand, and reason). The MDS indicated Resident 12 required partial/moderate assistance (helper does less than half the effort) for eating. The MDS indicated Resident 12 required substantial/maximal assistance (helper does more than half the effort) for oral hygiene, toileting hygiene, upper body dressing, lower body dressing, and personal hygiene and was dependent on facility staff for showering, bathing herself, and putting on/taking off footwear. During a review of Resident 12's Care Plan Report dated 1/14/2026, the Care Plan Report indicated the resident had a communication problem. The Care Plan Report indicated the resident's primary language was Korean and the resident was able to speak and understand simple English words. The Care Plan Report indicated goals for Resident 12 included being able to communicate through non-verbal gestures, Resident 12's language barrier would not interfere with the resident's ability to communicate, and that staff would anticipate and meet Resident 12's needs. The Care Plan Report indicated an intervention which included staff to provide Resident 12 with a visual and Korean communication board. During a concurrent observation and interview on 2/2/2026 at 12:19 PM with the Infection Preventionist (IP), in Resident 12's room, Resident 12 was observed without a Korean communication board at the bedside. The IP confirmed by stating that Resident 12's primary language was Korean, and the resident could speak and understand some English words. The IP was observed asking Resident 12 if she needed help with anything. Resident 12 was observed responding to the IP in a language that was not English. The IP stated he did not speak Korean. The IP stated there should have been a communication board at Resident 12's bedside so the resident could communicate her needs to the staff (in general) more easily. The IP stated that Resident 12 had a Korean communication board before but did not know what happened to it. The IP stated there was a potential for Resident 12 to not be able to easily convey her needs to staff if a Korean communication board was not available for the resident. 055157 Page 3 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0558 Level of Harm - Minimal harm or potential for actual harm During an interview on 2/2/2026 at 12:22 PM with the Director of Nursing (DON), the DON stated that residents should have communications boards in the room if the resident spoke another language (not English). The DON stated a communication board would help residents who spoke another language to covey their needs to staff. The DON stated there would be a potential for Resident 12 to not be able to communicate needs and resulting in a delay in care if without a Korean communication board at bedside. Residents Affected - Few During a review of Resident 74's admission Record, the admission record indicated the facility admitted Resident 74 on 4/25/2023 with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood). During a review of Resident 74's Care Plan Report dated 12/18/2025, the Care Plan Report indicated the resident had hearing problems related to hearing loss with an intervention to provide communication board as needed. During a review of Resident 74's Minimum Data Set (MDS – a resident assessment tool) dated 1/22/2026, the MDS indicated the resident had minimal difficulty hearing. During a concurrent observation and interview on 2/2/2026 at 10:37 AM in the doorway in Resident 74's room, with Restorative Nurse Assistant (RNA) 1, RNA 1 stated Resident 74 was going to the dining room. RNA 1 stated that Resident 74 did not have a communication board in his room. RNA 1 stated she (RNA 1) was able to speak a little Korean. RNA 2 stated Resident 74 understood a little English. During an interview on 2/2/2026 at 10:00 AM with Certified Nurse Assistant (CNA) 2, CNA 2 stated communication boards were in each room for those residents (unspecified) who spoke two languages. CNA 2 stated communication boards in the rooms (unspecified) were important. CNA 2 stated social services was responsible for placing a communication board in Resident 74's room. During an interview on 2/2/2026 at 12:22 PM with the Director of Nursing (DON), the DON stated that residents were to have communications boards in the room if the resident (unspecified) spoke another language (not English). The DON stated Resident 74 would be at risk for not being able to communicate needs. During a review of the facility's policy and procedure (P&P) titled Providing Meaningful Communications with Persons with Limited English Proficiency, dated 7/2025, the P&P indicated The Facility will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs, and other benefits.This facility will promptly identified the language and communication needs of the LEP person. If necessary, staff will use a language identification card (or I speak cards,) or posters to determine the language. 2. During a review of Resident 53's admission Record, the admission Record indicated the facility admitted Resident 53 on 6/27/2019 and readmitted the resident on 3/21/2025 with diagnoses that included acute respiratory failure (a life-threatening , sudden condition where the lungs cannot get enough oxygen into the blood) with hypoxia (a dangerous medical condition where the body tissues are starved of oxygen to function properly), unspecified lack of coordination(a broad, non-specific symptom where the person experiences difficulty with movement control, balance, or fine motor tasks), primary osteoarthritis(a progressive disorder of the joints, caused by a gradual loss of cartilage) left 055157 Page 4 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hand, metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the body), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), unspecified glaucoma (a group of eye disease that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), dementia (a progressive state of decline in mental abilities) in other diseases classified elsewhere, unspecified severity, without behavioral disturbance (acting out, agitated, aggressive or mood/personality changes), blindness, one eye, low vision other eye, unspecified eyes, ataxia (a lack of muscle control and coordination, causing shaky, unsteady, and clumsy movements). During a review of Resident 53's Care Plan Report dated 3/24/2025 indicated Resident 53 had vision problems. The Care Plan Report indicated interventions included was to teach Resident 53 on how to locate and use the call light. There were no specific indications documented on how the resident would receive instructions or what was to be taught to locate and use the call light as indicated on the care plan. During a review of Resident 53's Ophthalmology Exam Consult note dated 10/26/2025, the note indicated Resident 53 was unable to open his eyes. The note indicated Resident 53's left cornea (outermost clear layer of the eye) had opacity (cloudy, white, or scarred spot) and a right cataract (a clouding of your eyes' natural lens, like looking through a foggy window, which makes vision blurry and hazy). During a review of Resident 53's Minimum Data Set (MDS – a resident assessment tool) dated 11/26/2025, the MDS indicated Resident 53's ability to see in adequate light was highly impaired (reduced) and did not use corrective lenses (contacts, glasses, or magnifying glass). The MDS indicated resident 53 had severe cognitive (ability to think, understand, learn, and remember) impairment, had limitation in range of motion (ROM-the full distance and direction a joint[where two or more bones meet] can move, measured by how far it can bend, straighten, or twist) in the upper extremity (shoulder, elbow, wrist, hand) on one side and required substantial/maximal assistance (helper does more than half the effort) for eating, oral (mouth) hygiene, upper body dressing, personal hygiene, rolling left and right, sitting to lying, and lying to sitting on the side of the bed . During a concurrent observation in Resident 53's room and interview on 2/4/2026 at 12:17 PM, Resident 53 was observed lying in bed with his eyes closed and a push button call light next to the resident. Resident 53 responded yes to his name being called but did not open his eyes. Resident 53 was observed to have the ability to move his head slightly. Resident 53 was asked if he could push the call light for help, Resident 53 did not respond and did not respond to any other questions and was observed not moving his hand or fingers. During an interview on 2/4/2026 at 12:23 PM, with Certified Nuse Assistant (CNA) 2 stated Resident 53 could not use the call light and was not able to move his hands and fingers very much but could move his head. CNA 2 stated if Resident 53 needed help, he would not have been able to call for help and could not speak out. CNA 2 stated Resident 53 was dependent on the staff for all care and needs. During an interview on 2/4/2026 at 12:26 PM with Registered Nurse (RN 2), RN 2 stated Resident 53 had been in the facility for a long time and was not sure if the resident was able to use the call light. RN 2 stated a push pad call light (a large soft pad designed for residents with limited hand strength) would have been ideal for Resident 53. 055157 Page 5 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/4/2026 at 2:44 PM, with the Director of Nursing (DON), stated a resident who had limited ROM, was blind and had dementia would not have been able to use a traditional call light button. The DON stated Resident 53 would not have been able to call for assistance and would not have had any of his needs tended to. The DON stated a push pad call light would be more appropriate for Resident 53. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting dated 1/2025, the P&P indicated Appropriate care and services will be provided for residents who are unable to carry out ADLS independently. The P&P indicated .in accordance with the plan of care, including appropriate support and assistance with communication. any functional communication system. During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Accommodation of Needs dated 1/2025, the P&P indicated The resident's individual needs and preferences shall be accommodated to the extent possible. The P&P indicated The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. 055157 Page 6 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0583 Keep residents' personal and medical records private and confidential. 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 ensure one of one sampled resident (Resident 11's) medical information was kept private from unintended public view. This deficient practice had the potential to result in a breach of Resident 11's privacy and confidentiality.Findings: During a review of Resident 11's admission Record (a document containing demographic and diagnostic information) dated 2/4/2026, the admission record indicated, Resident 11 was originally admitted to the facility on [DATE] and readmitted on [DATE]. During an observation on 2/4/2026 at 1:27 PM in the facility's hallway near Station 2, a computer screen on a medication cart a computer screen was observed to have been left on and unattended with a page showing Resident 11's medical information. The computer screen indicated Resident 11's name, date of birth , physician name, room number, code status, allergy information and physician orders. The computer screen indicated, Monitor blood pressure for as needed clonidine order, monitor pain level every shift using pain scale, MiraLAX ([generic name - polyethylene glycol] a medication used to treat constipation) oral packet 17 gram ([gm] a unit of measurement for mass) and ondansetron (a medication used to treat nausea) hydrochloride (HCl) oral tablet 4 milligrams ([mg] a unit of measurement for mass). During a concurrent observation and interview on 2/4/2026 at 1:31 PM with the Licensed Vocational Nurse (LVN) 5, a computer screen on a medication cart was observed to have been left on and unattended facing the public hallway. LVN 5 was observed working at Nurses' Station 2 desk looking at another computer screen. The computer screen on the medication cart indicated Resident 11's medical information. LVN 5 stated she was unaware that the computer screen was open, and she was very careful about locking her medication cart computer. LVN 5 stated, oh no, the computer screen with Resident 11's medical information should not be open for public view because of all the information on it. LVN 5 stated it was important to ensure that Resident 11's medical information was always protected and kept private. During an interview on 2/6/2026 at 3:03 PM with the Director of Nursing (DON), the DON stated facility resident's information should always be kept private. The DON stated the computer screen with residents' information should not have been left open to public view. During a review of the facility's policy and procedure (P&P) titled Resident Dignity & Personal Privacy, dated 01/2025, the P&P indicated, The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy. The P&P indicated, Each resident's right to personal privacy includes the confidentiality of his or her personal and clinical affairs. During a review of the facility's P&P titled, Specific Medication Administration Procedures - Administration Procedures For All Medications, dated 1/20/2025, the P&P indicated, Privacy: Secure (cover) records containing protected health information, (e.g., Medication Administration Records (MARs) and Treatment Administration Records (TARs). Residents Affected - Few 055157 Page 7 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based on interview and record review, the facility failed to ensure to obtain an informed consent (voluntary agreement to accept treatment and/or procedure after receiving education regarding the risks, benefits, and alternatives offered) for the use of antipsychotic medication (medication used to treat the symptoms of schizophrenia, a mental illness that is characterized by disturbances in thought) from a resident who did not have the capacity to make healthcare decisions (the ability to use and understand information to make a decision and communicate any decision made) for one of five sampled residents (Resident 8). This failure had the potential to result to restrict Resident 8's movement and had the potential for Resident 8 to receive unnecessary psychotropic (medication that affect brain chemicals to alter mood, thoughts, perceptions, and behaviors, primarily used to treat mental illnesses) medication.Findings:During a review of Resident 8's admission Record, the admission Record indicated the facility re-admitted Resident 8 on 8/2/2025 with diagnoses that included dementia (a progressive state of decline in mental abilities), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and schizophrenia. The admission Record indicated Resident 8 was responsible for herself. During a review of Resident 8's History and Physical (H&P) dated 8/3/2025, the H&P indicated the resident did not have the capacity to make complex healthcare decisions; however, the resident was able to decide for activity of daily living and was able to make her needs known. During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool) dated 9/29/2025, the MDS indicated the resident's preferred language was Vietnamese. The MDS indicated Resident 8 had severe cognitive impairment (impairment in the ability to think, understand, and reason) with a BIMS score (a 0-15 point assessment used in long-term care to measure a person's cognitive function, particularly memory, orientation, and ability to recall information; 0-7 indicates severe cognitive impairment) of 4. The MDS indicated Resident 8 was taking antipsychotic medication. During a review of Resident 8's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 10/21/2025 for Risperidone (a type of antipsychotic medication) 2 Milligrams (mg, a unit of mass) via g-tube (a feeding tube inserted through the abdomen directly into the stomach, used to deliver nutrition, fluids, and medication) at bedtime for schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) manifested by derogatory auditory hallucination (a symptom commonly found in schizophrenia where individuals hear voices insulting, belittling, or criticizing them). During a review of Resident 8's Informed Consent Verification Form dated 10/21/2025, the Informed Consent Verification Form indicated Registered Nurse 2 (RN 2) verified that Resident 8 provided informed consent for the use of Risperidone 2 mg via the g-tube at bedtime. During a review of Resident 8's Medication Administration Record (MAR) dated 10/21/2025 - 10/31/2025, the MAR indicated the resident received 11 doses of Risperidone 2 mg. During a review of Resident 8's Behavioral Management Team Psychotropic Medication Review dated 11/6/2025, the Behavioral Management Team Psychotropic Medication Review indicated Resident 8 received Risperidone 2 mg at bedtime for schizoaffective disorder manifested by derogatory auditory hallucinations. The Behavioral Management Team Psychotropic Medication Review indicated the resident had no change in her behavioral symptoms. The Behavioral Management Team Psychotropic Medication Review indicated a Gradual Dose Reduction (GDR, the step-by-step reduction of a medication's dosage over time, with the goal of reaching the lowest effective dose or completely discontinuing the medication) was contraindicated (should not be done) because Resident 8's behavior persisted (continued to exist). The Behavioral Management Team Psychotropic Medication Review did not indicate Resident 8's capacity for making health care decisions 055157 Page 8 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was reviewed. During a review of Resident 8's MAR dated 11/1/2025 - 11/30/2025, the MAR indicated the resident received 30 doses of Risperidone 2 mg. During a review of Resident 8's Behavioral Management Team Psychotropic Medication Review dated 12/13/2025, the Behavioral Management Team Psychotropic Medication Review indicated Resident 8 was receiving Risperidone 2 mg at bedtime for schizoaffective disorder manifested by derogatory auditory hallucinations. The Behavioral Management Team Psychotropic Medication Review indicated Resident 8 had an increase in behavioral symptoms. The Behavioral Management Team Psychotropic Medication Review indicated a GDR was contraindicated because Resident 8's behavior persisted. The Behavioral Management Team Psychotropic Medication Review did not indicate Resident 8's capacity for making health care decisions was reviewed. During a review of Resident 8's MAR dated 12/1/2025 - 12/31/2025, the MAR indicated the resident received 31 doses of Risperidone 2 mg. During a review of Resident 8's Behavioral Management Team Psychotropic Medication Review dated 1/30/2025, the Behavioral Management Team Psychotropic Medication Review indicated Resident 8 was receiving Risperidone 2 mg at bedtime for schizoaffective disorder manifested by derogatory auditory hallucinations. The Behavioral Management Team Psychotropic Medication Review indicated a GDR was contraindicated for Resident 8. The Behavioral Management Team Psychotropic Medication Review did not indicate Resident 8's capacity for making health care decisions was reviewed. During a review of Resident 8's MAR dated 1/1/2026 - 1/31/2026, the MAR indicated the resident received 31 doses of Risperidone 2 mg. During a concurrent interview and record review on 2/05/2026 at 12:11 PM with Licensed Vocational Nurse 3 (LVN 3), Resident 8's Informed Consent Verification Form dated 10/21/2025 was reviewed. LVN 3 stated that she (LVN3) was assigned to care for Resident 8 and was familiar with the resident. LVN 3 stated Resident 8 was confused but could make her needs known. LVN 3 stated Resident 8 had impaired cognition and did not have the capacity to make medical decisions. LVN 3 stated that Resident 8 was self- responsible and did not have family. LVN 3 stated Resident 8 was taking Risperidone 2 mg every night for schizoaffective disorder. LVN 3 stated that the Informed Consent Verification Form dated 10/21/2025 indicated consent for the administration of Risperidone 2 mg was obtained from the resident. LVN 3 stated that informed consent for Risperidone should not have been taken from Resident 8 because the resident did not have the capacity to make healthcare decisions. LVN 3 stated that the aging department should have been contacted for Resident 8. LVN 3 stated the aging department helped make decisions for a resident if the resident did not have capacity to make healthcare decisions. LVN 3 stated if consent was obtained from a resident (in general) for Risperidone when the resident did not have capacity, the resident may not be aware of what kind of medication they were taking. During a concurrent interview and record review on 2/5/2026 at 12:19 PM with RN 2, Resident 8's Informed Consent Verification Form dated 10/21/2025 was reviewed. RN 2 stated he was familiar with Resident 8. RN 2 stated Resident 8 was confused and could not make medical decisions. RN 2 stated Resident 8 had a history of dementia and schizophrenia. RN 2 stated informed consent for Risperidone 2mg dated 10/21/2025 was obtained from Resident 8, however, the resident did not have the capacity to make medical decisions. RN 2 stated when a resident (in general) was unable to make health care decisions, they would normally ask the family for consent. RN 2 stated Resident 8 did not have family and was self-responsible. RN 2 stated that Resident 8's physician should have been informed the resident did not have capacity to make healthcare decisions. RN 2 stated Resident 8 should have been referred to the aging department. RN 2 stated there was a potential for Resident 8 to not know about the medication she was taking. RN 2 stated there was a potential for Resident 8 to not know about the risks and benefits of taking Risperidone if consent was obtained from the resident when the resident did not have capacity to make healthcare decisions. During a concurrent interview/record 055157 Page 9 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few review on 2/5/2026 at 12:28 PM with the Minimum Data Set Coordinator (MDSC), Resident 8's Informed Consent Verification Form dated 10/21/2025 was reviewed. The MDSC stated she was familiar with Resident 8. The MDSC stated Resident 8 was able to answer simple direct questions but was confused. The MDSC stated Resident 8 had a history of dementia and schizophrenia. The MDSC stated Resident 8 had severely impaired cognition which indicated the resident did not have the capacity to make complex healthcare decisions. The MDSC stated informed consent for Risperdal 2 mg dated 10/21/2025 was obtained from Resident 8. The MDSC stated Resident 8 did not have the capacity to make healthcare decisions when informed consent was obtained from the resident on 10/21/2025. The MDSC stated informed consent for antipsychotic medication was usually obtained from the resident; but if the resident did not have capacity, consent would then be obtained from family or a friend. The MDSC stated if the resident did not have family, the resident would be referred to the aging department. The MDSC stated Resident 8 did not have family and was self-responsible, however, the resident did not have the capacity to make healthcare decisions. The MDSC stated Resident 8 should have been referred to the aging department. The MDSC stated there was potential for Resident 8 to not be aware of the risks and benefits of the medication she was taking if consent was obtained for Risperidone when the resident did not have capacity to make healthcare decisions. During an interview using an interpreter on 2/5/2026 at 12:44 PM with Resident 8, Resident 8 was asked if she (Resident 8) knew about Risperidone. Resident 8 did not acknowledge the interpreter and did not answer the questions the interpreter asked. Resident 8 repeatedly stated she (Resident 8) was cold. During a concurrent interview and record review on 2/5/2026 at 12:51 PM with the Director of Nursing (DON), Resident 8's Informed Consent Verification Form dated 10/21/2025 was reviewed. The DON stated Resident 8 did not have mental capacity. The DON stated Resident 8's decision making ability was not intact and was not normal. The DON that when obtaining informed consent for a resident (in general) who did not have decision making capacity, the person who was identified as the responsible party could give consent. The DON stated this may be a family member or a friend who was designated by the resident. The DON stated if the resident (in general) did not have a responsible party, then consent must be obtained through the IDT (Interdisciplinary Team, a collaborative group of professionals-including nurses, physicians, therapists, social workers, and dieticians-who work together to develop and implement personalized, patient-centered care plans) or physician. The DON stated Resident 8 did not have an IDT meeting to discuss the resident's capacity for making healthcare decisions. The DON stated the purpose of informed consent was to ensure that the resident was aware of what was being done and what medication they were receiving. The DON stated the residents (in general) must understand the consequences of the medication they were taking. The DON stated an informed consent for Risperidone dated 10/21/2025 was obtained from Resident 8 when the resident did not have the capacity to give consent. The DON stated the licensed nurses (in general) should have notified Resident 8's physician about the resident's capacity. The DON stated Resident 8 should have had an IDT meeting for her capacity to make healthcare decisions. The DON stated there was a potential for Resident 8 to not be aware of the medications she (Resident 8) was taking and not be aware of the risks and consequences of the medication because an informed consent for Risperidone was obtained when the resident could not make healthcare decisions. During a review of the facility's Policy and Procedure (P&P) titled Interdisciplinary Team Resident Representative from Long Term Care Patient Representative Program Policy and Procedure dated 9/4/2024, the P&P indicated The purpose of this policy is to provide a process for making ethically and medically appropriate treatment decisions on behalf of persons who lack health care decision-making capacity. This policy may be used when all of the following conditions are met:1. The resident has been determined 055157 Page 10 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few by the primary physician (with assistance from appropriate consulting physicians if necessary) to lack capacity to make health care decisions.2. No agent under a durable power of attorney for health care, conservator, orally-designated surrogate or guardian has been designated to act on behalf of the patient.3. There is no individual health care directive or instruction in the patient's medical record or other available sources that would eliminate the need for a substitute decision maker.4. No decision maker, family member, or friend can be located who is reasonably available and who is willing and able to serve. When the facility receives from the attending physician an order for medical intervention that requires informed consent and determination that resident lacks capacity to make healthcare decisions the facility will promptly seek a friend or relative to serve as patient representative and participate in the IDT review. The facility should document efforts in resident's records. If the facility is unable to locate a friend or relative within 72 hours of physician's notice the facility must submit a request for Public Patient Representative from the Long-Term Care Patient Representative Program. Convene the IDT Review which can be held in-person or virtually and must include:1. The physician's assessment of resident's condition2. The reason for the proposed medical intervention3. A discussion of whether the proposed treatment is consistent with the resident's preferences/prior expressions of their healthcare wishes. The IDT shall give particular consideration to the resident's preferences/prior expressions of health care wishes unless they are inconsistent with the best interest of the resident, require medically ineffective health care, or contrary to generally accepted health care standards.4. The type of medical intervention - its frequency and duration and risks and benefits5. Probable impact on the resident's condition, with or without the intervention or inappropriateness6. Any reasonable alternatives considered or utilized and reasons for their discontinuance or inappropriateness. During a review of the facility's P&P titled Psychotropic Medication Use dated 1/2025, the P&P indicated When determine whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. The evaluation will attempt to clarify whether.the actual or intended benefit of the medication is understood by the resident/representative. Residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. 055157 Page 11 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review the facility failed to report an injury of unknown origin to the State Survey Agency (SSA, the Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Health, which is responsible for nursing facility certification and for conducting surveys to determine compliance with Medicare and Medicaid requirements) and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) within 2 hours when one of eight sampled residents (Resident 62) developed an acute fracture of the left distal fibula (broken left ankle bone). This failure had the potential to result in a delay of the onsite inspection by the SSA and had the potential for Resident 62's to suffer more injuries.Findings: During a review of Resident 62's admission Record, the admission Record indicated the facility admitted the resident on 8/12/2024 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial paralysis affecting one side of the body), dementia (a progressive state of decline in mental abilities), adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), osteoarthritis (a progressive disorder of the joints caused by a gradual loss of cartilage), history of falling, age-related osteoporosis (weak and brittle bones due to lack of calcium and vitamin D), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 62's Minimum Data Set (MDS, a resident assessment tool) dated 11/10/2025, the MDS indicated the resident had moderately impaired cognition (impairment in the ability to think, understand, and reason). The MDS indicated Resident 62 required partial/moderate assistance (helper does less than half the effort) for eating, oral hygiene, and upper body dressing. The MDS indicated Resident 62 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, showering/bathing herself, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 62's 72 Hours Charting - Change of Condition progress note dated 1/27/2026 at 12:27 PM, the progress note indicated that during morning (1/27/2026) assessment Resident 62 was noted with left ankle swelling and moderate pain. The progress note indicated Resident 62's left lateral (the side of the body that is away from the midline of the body) ankle also had a bluish discoloration (a change in natural color) of the skin. The progress note indicated Resident 62's left ankle was stabilized for safety purposes. The progress note indicated Resident 62 was provided with 50 milligrams (a unit of mass) of Tramadol (a medication used to treat moderate to severe pain) for moderate pain. The progress note indicated Resident 62's physician was notified and a new order for a left ankle three view (three distinct two-dimensional images) x-ray (a type of medical imaging that uses radiation to take picture of the inside of the body) was received and carried out. During a review of Resident 62's Radiology Interpretation dated 1/27/2026, the Radiology Interpretation indicated Resident 62 had an acute fracture of the left distal fibula. During a review of Resident 62's 72 Hour Charting progress note dated 1/28/2026 2:58 AM, the progress note indicated the resident's x-ray results were received and faxed to the resident's physician. The progress note indicated Resident 62's physician response to the x-ray result was pending. During a review of Resident 62's Health Status Note dated 1/28/2026 at 10:38 AM, the Health Status Note indicated a physician order was received to transfer Resident 62 to General Acute Care Hospital 1 (GACH 1) for further evaluation and treatment for the resident's acute fracture of the distal fibula. During a review of Resident 62's Discharge Summary progress note dated 1/28/2026 at 12:18 PM, the 055157 Page 12 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few progress note indicated the resident was transferred out to GACH 1 via a gurney for further evaluation and treatment of the resident's acute fracture of the distal fibula. During a review of Resident 62's GACH 1 documentation dated 1/28/2026 at 6:50 PM, the documentation indicated that based on the resident's evaluation it was difficult to tell whether the resident had a subacute (a bone injury in the process of healing) or acute fracture in the left distal fibula. The documentation indicated Resident 62 had a non-operative fracture. The documentation indicated that based on discussion with orthopedics (the branch of medicine dealing with conditions affecting the bones or muscles) the most conservative treatment for Resident 62 would be to treat the resident for an acute fracture. The documentation indicated Resident 62 was to use a CAM boot (a specialized, rigid walking brace designed to immobilize the foot and ankle, protecting injuries like fractures) for protection until the resident could follow and get assessed by orthopedics. The documentation indicated Resident 62 was to be non-weight bearing for six weeks. During a review of Resident 62's admission Summary progress notes dated 1/28/2026 at 7:10 PM, the progress notes indicated the resident was re-admitted at the facility with a CAM boot on her left leg. The progress note indicated Resident 62 was to continue wearing the CAM boot to immobilize her left leg until the resident's orthopedic appointment. During an observation and interview on 2/4/2026 at 1:35 PM with Resident 62, in the resident's room, the resident was observed with a CAM boot to her left leg. Resident 62 was unable to answer the surveyor's questions about why she was wearing the CAM boot. During an interview on 2/4/2026 at 1:51 PM with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated she was familiar with Resident 62 and had noticed the resident's left ankle swelling on 1/27/2026. LVN 3 stated that on 1/27/2026 she noticed Resident 62 was having left ankle swelling and pain. LVN 3 stated Resident 62's left ankle was also slightly discolored. LVN 3 stated she called Resident 62's physician to notify him of the resident's x-ray results. LVN 3 stated Resident 62's physician gave orders to send the resident to the hospital. LVN 3 stated Resident 62 was sent out to the hospital by Registered Nurse 2 (RN 2). LVN 3 stated she could not figure out how Resident 62 got the left ankle swelling. LVN 3 stated she did not know how Resident 62 developed the fracture. LVN 3 stated Resident 62 was confused and could not tell her (LVN 3) how the fracture happened. LVN 3 stated Resident 62 did not fall. LVN 3 stated she did not report Resident 62's injury to the SSA because it was not abuse. During an interview on 2/4/2026 at 2:38 PM with Registered Nursing 2 (RN 2), RN 2 stated he transferred Resident 62 to the hospital after the resident's x-ray results indicated the resident had an acute fracture. RN 2 stated he did not know how the resident developed the fracture. RN 2 stated he did not report Resident 62's fracture to the SSA or ombudsman. RN 2 stated Resident 62's fracture should have been reported as it was an unusual occurrence and injury of unknown origin. RN 2 stated there was a potential for a delay in the investigation of the resident's injury or for the injury to get worse because it was not reported to the SSA or ombudsman. During an interview on 2/5/2026 at 1:10 PM with the Director of Nursing (DON), the DON stated she was familiar with Resident 62 and was aware of the resident's left ankle fracture. The DON stated staff had noticed Resident 62 had some discoloration and swelling to her left ankle. The DON stated Resident 62's physician was notified and ordered a x-ray of the resident's ankle. The DON stated Resident 62's x-ray showed the resident had a left ankle fracture. The DON stated Resident 62's physician was notified of the resident's x-ray results and fracture and ordered for the resident to be transferred to the hospital. The DON stated she did not know how the resident developed a fracture. The DON stated she investigated and found the resident did not have a fall. The DON stated she interviewed the staff that took care of Resident 62 and found there was no rough handling of the resident. The DON stated Resident 62's fracture was an injury of unknown origin because she did not know 055157 Page 13 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few how the resident obtained the fracture and the source of the fracture was not clear. The DON confirmed by stating she did not report Resident 62's injury of unknown origin to the SSA or ombudsman. The DON stated an injury of unknown origin should have been reported to the SSA and ombudsman within two hours. The DON stated there could have been a potential for a delay in investigation by the SSA if an injury of unknown origin is not reported. During a telephone interview on 2/6/2026 at 10:14 AM with RN 4, RN 4 stated she received Resident 62's x-ray results that indicated the resident had a fracture of the left distal fibula on 1/28/2026 at around 2 AM. RN 4 Stated that she did not report Resident 62's injury of unknown origin to the department, law enforcement, or ombudsman because it was not abuse. RN 4 stated only abuse had to be reported immediately. During an interview on 2/6/2025 at 3:01 PM with the Administrator, the Administrator stated she was aware of Resident 62's x-ray that indicated the resident had a fracture. The Administrator stated that she did not initially know how Resident 62 developed the fracture in her left ankle. The Administrator stated that she and the DON had to investigate to determine what could have happened to Resident 62's left ankle. The Administrator stated she did not report Resident 62's injury to the SSA or ombudsman. The Administrator stated Resident 62's injury should have been reported to the SSA and ombudsman immediately once the injury was found. The Administrator stated there was a potential for there to be a delay in an investigation of Resident 62's injury because the injury was not reported to the SSA and ombudsman. During a review of the facility's Policy & Procedure (P&P) titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 10/14/2025, the P&P indicated It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse an do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law. 055157 Page 14 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 ensure to follow safe hazardous (dangerous) medication/drug handling procedures before the preparation and administration of medications that required to be administered with caution for one of six sampled residents (Resident 4) by failing to: -Ensure that on 2/5/2026 at 9:13 AM Licensed Vocational Nurse 3 (LVN3) followed safe hazardous drug handling procedures and checked the National Institute for Occupational Safety and Health (NIOSH, a federal agency responsible for research and recommendations to prevent work-related injuries, illnesses, and deaths) list of drugs before LVN3 prepared and administered Casodex ([generic name -bicalutamide], a medication used to treat progressive prostate cancer [a serious medical condition characterized by an uncontrolled growth of cells within the prostate gland [an organ in the male reproductive system]) and finasteride (a medication used to treat symptoms of benign prostatic hyperplasia ([BPH] a noncancerous enlargement of the prostate that commonly affects men, causing lower urinary tract symptoms like weak stream, frequency, urgency, and incomplete emptying) to Resident 4 via gastrostomy tube ([G-tube] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) This failure had the risk for Resident 4, LVN3, and the environment to be exposed to hazardous medication particles (very small pieces) that could cause skin and respiratory complications, and could cause reproductive/hormonal toxicity (refers to the ability of chemicals, drugs, or environmental agents to cause harmful effects on the ability to conceive, carry a pregnancy to term, or develop normally) . Findings:During a review of Resident 4's admission Record (a document containing demographic and diagnostic information), dated 2/5/2026, the admission Record indicated the facility originally admitted Resident 4 on 6/17/2024 and readmitted on [DATE] with diagnoses that included but not limited to BPH without lower urinary tract symptoms, encounter for attention to gastrostomy (a surgical or endoscopic creation of an opening (stoma) into the stomach to insert a feeding tube (G-tube) for delivering nutrition, fluids, or medication directly, or for gastric decompression). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 4's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was left blank. The MDS indicated Resident 4 was dependent on the facility staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as oral hygiene, toileting hygiene, showering upper and lower body dressing, putting on/taking off footwear and personal hygiene and the ability to eat was not attempted due to medical condition or safety concerns. During a concurrent observation and interview on 2/5/2026 at 9:13 AM with Licensed Vocational Nurse 3 (LVN 3), LVN 3 prepared seven medications for administration via G-tube. At the time of preparation, LVN 3 was wearing a surgical mask and personal eyeglasses. LVN 3 wore a blue surgical gown and one pair of regular gloves before entering Resident 4's room. that included but not limited to the following medications:a. One tablet of bicalutamide 50 milligram ([mg] a unit of measurement for mass)b. One tablet of finasteride 5 mgDuring a concurrent observation and interview on 2/5/2026 at 9:13 AM LVN 3 was observed removing one tablet of bicalutamide 50 mg from the medication bubble pack (sealed card containing individual, daily, or weekly doses of medication in clear, push-through plastic bubbles) without wearing gloves by popping it out into a medicine cup. LVN 3 then removed a finasteride 5 mg tablet from the medication bubble pack into a medicine cup. LVN 3 placed the bicalutamide 50 mg tablet in a small transparent plastic bag and then crushed the tablet using a crushing device without wearing any gloves. LVN 3 wore a pair of gloves on Residents Affected - Few 055157 Page 15 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few both hands, placed the finasteride 5 mg tablet in a small transparent plastic bag and then crushed the tablet using a crushing device. LVN 3 stated she wore gloves while crushing finasteride because she could touch it accidentally, but while removing from the medication bubble pack, I was not going to touch tablet. LVN 3 stated the finasteride was in hazardous list of medications, so she needed to wear gloves especially for women who could become pregnant or are at childbearing age. LVN 3 showed medication bubble pack for bicalutamide 50 mg, and the pharmacy label indicated, Take one tablet by mouth daily with an additional label directions changed refer to chart but no instructions to wear gloves or to follow hazardous drugs handling procedures. LVN 3 showed medication bubble pack for finasteride 5 mg and the pharmacy label indicated, Take one tablet by mouth daily *Use gloves when handling*. LVN 3 stated the cards indicated by mouth but the order was changed in eMAR to indicate by g-tube. LVN 3 then removed gloves and resumed crushing the remainder of Resident 4's medications. During an observation on 2/5/2025 from 9:34 AM to 10:09 AM in Resident 4's room, LVN 3 placed all the medications in their individual medicine cups on a bedside cart and dissolved each medication separately that included Casodex and finasteride in five milliliters ([mL] a unit of measurement for volume) of water and administered one-by-one via G-tube. During a review of Resident 4's medication reconciliation on 2/5/2026, Resident 4's Order Summary Report, dated 2/4/2026, the order summary report indicated but not limited to the following physician orders: Casodex ([generic name - bicalutamide]) 50 mg, Give 1 tablet via G-tube one time a day for prostate cancer (CA), order date 1/23/2026, start date 1/24/2026. Finasteride 5 mg, Give 1 tablet via G-tube one time a day for BPH, wear gloves when handling medication, order date 1/23/2026, start date 1/24/2026. During an interview on 2/5/2026 at 1:18 PM with LVN 3, LVN 3 stated she (LVN3) only wore gloves for finasteride because there were instructions to wear a single pair of gloves. LVN 3 stated she (LVN3) did not see instructions to wear gloves or double gloves for either Finasteride or Casodex. LVN 3 stated she (LVN3) would need to research to check what Casodex was for and then LVN 3 stated she (LVN3) found from her research that she (LVN3) had to be careful while handling Casodex because these medications had a risk for baby or toxicity to babies if handled or touched by women who were young, pregnant or those with childbearing age. LVN 3 stated she (LVN3) needed to inform pharmacy because Casodex did not indicate it was a hazardous drug on the pharmacy label. LVN 3 stated she (LVN3) researched online regarding finasteride and stated finasteride must be handled with care because it belonged to the hazardous drug class that could be absorbed through skin posing significant risk to developing male fetus, pregnant women or those who could become pregnant and they must not handle broken or crushed tablet. LVN 3 stated there was a risk for skin irritation, respiratory problems, or those with women childbearing age or immunocompromised (people who can easily get sick) could have issues with neonatal toxicity or could affect fetus. LVN 3 stated there was a risk of breathing in the particles while preparing Resident 4's finasteride and Casodex so it was important to wear a N95 mask (a mask that is National Institute for Occupational Safety and Health [NIOSH] approved disposable respirators designed to filter at least 95% of airborne particles, offering superior protection against viruses, bacteria, and dust compared to cloth masks). During an interview on 2/5/2026 at 3:10 PM with the Director of Nursing (DON), the DON stated she (DON) would need to do some research and look on WebMD (a health search engine for drug information) and google to learn more about Casodex. DON stated it was a nonsteroidal [not a steroid], anti-cancer medication. The DON stated she (DON) would check with the pharmacy to double check about Casodex that she (DON) was not aware of. The DON stated hazardous drugs could be very strong and toxic so should not have been handled with bare hands. The DON stated the healthcare personnel (in general) could get gastrointestinal (relating to the stomach) side effects. The DON stated, 055157 Page 16 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pregnant women should follow special precautions, handle carefully, wear gloves and should not have had direct contact. The DON stated there would be a risk for the Casodex to be absorbed via skin for the nurse (unidentified) and could also pose a safety risk for the resident (unidentified) if they took the Casodex out in their hands. The DON stated there was a lot of risk for pregnant women and pregnant women should not even handle crushed or broken tablets of finasteride. The DON stated there would be a risk for finasteride to be absorbed via skin for the nurse and would have been a risk for the resident if they took the medication out in their hands. During an interview on 2/6/2026 at 3 PM with the DON, the DON stated the facility did not have the necessary chemotherapy (cancer treatment that uses powerful drugs) gloves or gowns to aid in safe preparation and the administration of hazardous drugs. During a review of the facility's P&P titled, United States Pharmacopeia (USP) Chapter <800>: Hazardous Drug, dated 1/20/2025, the P&P indicated, USP General Chapter <800> provides standards for safe handling hazardous drugs to minimize the risk of exposure to healthcare personnel, patients and the environment.Facilities are recommended to check with local and state regulatory agencies to verify requirements for Hazardous Drug Handling. The National Institute for Occupational Safety and Health (NIOSH) considers a drug to be hazardous if it exhibits one or more of the following characteristics in humans or animals: carcinogenicity, teratogenicity or developmental toxicity, reproductive toxicity, organ toxicity at low doses, genotoxicity. The P&P indicated, The facility must develop and maintain a health and safety management system which shall, at a minimum, include the following: A. List of Hazardous Drugs (HDs), B Facility and engineering controls; .E.Proper use of appropriate Personal Protective Equipment (PPE); and F. Policies for HD waste segregation and disposal. This policy applies to all healthcare personnel who handle HD preparations and all entities that store, prepare, transport, or administer HDs. The P&P indicated a list of Hazardous Medications - Quick Safety Guide with Most Common Hazardous Medications (Skilled Nursing Facility [SNF] / Long-Term Care [LTC]), the list indicated but not limited to Casodex (Bicalutamide) with the key risk of reproductive/hormonal toxicity with the instructions of ‘crushing not allowed', and Proscar (Finasteride), with the key risk of teratogenic (pregnancy risk) with instructions of ‘crushing not allowed'. The Hazardous Medications - Quick Safety Guide indicated, Safe Handling Guidelines that indicated to always wear chemo-rated gloves when handling hazardous medications. Do NOT crush, split, or open hazardous tablets or capsules unless pharmacy-approved containment is used. Avoid direct contact with powder, residue or bodily fluids when applicable.If swallowing difficulty exists, request alternative formulations or therapies. Reminder: When in doubt, treat the medication as hazardous and consult pharmacy before altering dosage form. 055157 Page 17 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review, the facility failed to provide a Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation for one of four sampled residents (Resident 14) with ROM limitations, after identifying a decline in range of motion (ROM, full movement potential of a joint) on 5/14/2025, to obtain a baseline measurement, adjust the splint to the right knee, set a goal for the splint wear tolerance (amount of time a person could wear a splint before experiencing discomfort or skin irritation), monitor the skin, and train the RNA on applying the splint establish goals for the splint. As a result, a right knee extension (straightening) splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) was placed on Resident 14 without a PT Evaluation, placing Resident 14 at risk of developing additional ROM limitations and skin integrity (health and condition of the skin) issues. Findings: During a review of Resident 14's admission Record, the admission Record indicated the facility originally admitted Resident 14 on 11/18/2022 and readmitted Resident 14 on 1/8/2026. The admission Record indicated Resident 14's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following nontraumatic intracerebral hemorrhage (bleeding in the brain tissue) affecting the left non-dominant side, dysphagia (difficulty swallowing), aphasia (disorder that makes it difficult to speak), and contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) of the left elbow, left hand, both knees, and the left ankle. During a review of Resident 14's Joint Mobility Assessment (JMA, brief assessment of a resident's range of motion in each joint of both arms and legs), dated 12/10/2024, the JMA indicated Resident 14 had moderate ROM limitations (50-75 percent [%] limitation of normal joint movement) in the left shoulder, left hand, left hip, left knee, and minimal ROM limitations (25-50% limitation of normal joint movement) in the left elbow and ankle. The JMA indicated Resident 14 had within functional limits (WFL, sufficient joint movement without significant limitation) ROM on the right shoulder, elbow, both wrists, right hand, right hip, right knee, and right ankle. During a review of Resident 14's quarterly JMA, dated 5/14/2025, the JMA indicated Resident 14 did not have any change of condition noted on both arms and the leg. The JMA indicated Resident 14's right knee was always on a bending position and the resident would benefit from a right knee extension splint to prevent tightness or contracture. During a review of Resident 14's physician's orders, dated 5/15/2025, the physician's order indicated for the Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) to perform gentle passive range of motion (PROM, movement of a joint through the range of motion with no effort from person) to both legs then apply both knee extension splints and the left ankle splint for two to four hours or as tolerated with skin checks every two hours, seven times per week. During a review of Resident 14's physician's orders, dated 1/8/2026, the physician's orders indicated for the RNA to perform gentle PROM on the left arm, applications of the left elbow extension splint and towel/hand roll for up to 2 hours, seven times per week as tolerated. Another physician's order, dated 1/8/2026, indicated for the RNA to perform gentle PROM exercises to both legs then apply both knee extension splints and the left ankle splint for two to four hours or as tolerated with skin checks every two hours, seven times per week. During an interview on 2/2/2026 at 10:35 a.m. with the Director of Rehabilitation (DOR), the DOR stated the purpose of the JMA was to obtain a resident's (in general) baseline (reference point) ROM in both arms and legs. The DOR stated the therapist would then ask the nurses to request therapy orders from the physician for an evaluation, when a change was found on the JMA. During an 055157 Page 18 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few observation on 2/4/2026 at 3:18 p.m. in the resident's room, Resident 14 was observed lying in bed with the head-of-bed elevated. Resident 14 was observed to have active movement in the right arm. Blankets covered both Resident 14's legs. During an observation of Resident 14's RNA session on 2/5/2026 at 9:24 a.m. with Restorative Nursing Aide (RNA 1) in the resident's room. Resident 14 was observed lying in bed with the left shoulder rotated toward the body, the left elbow bent, the left wrist slightly bent, and the left fingers bent into a closed fist. RNA 1 performed exercises on Resident 14's left shoulder, elbow, and hand. RNA 1 then applied a left elbow extension splint and a gauze (woven cotton blend wound dressing) roll in the left hand. Resident 14's left leg was positioned in hip flexion (bent at the hip joint toward the body), knee flexion (bent), and ankle plantarflexion (ankle bent with toes pointing away from the body). RNA 1 performed exercises to the left hip, knee, and ankle. RNA 1 then applied a left knee splint, but Resident 14 did not want RNA 1 to apply the left ankle splint. Resident 14's right leg was bent at the knee joint. RNA 1 performed right hip and knee exercises and then applied the right knee splint. During a concurrent interview and record review on 2/5/2026 at 12:17 p.m. with the DOR, Resident 14's JMA, dated 5/14/2025, was reviewed. The DOR stated the professional standard for providing a splint to a resident (in general) included to screen the resident for any changes, obtain a physician's order for therapy services, and evaluate the resident to establish goals for splint wear tolerance. The DOR stated the splint would then be ordered, PT treatment would be provided, and the RNA would be trained on the application of the splint. The DOR reviewed Resident 14's JMA, dated 5/14/2025 completed by the DOR. The DOR stated Resident 14's right knee was consistently in a bent position and recommended a right knee extension splint to prevent muscle tightness or the development of contractures. The DOR stated the physician should have been contacted to request an order for a PT Evaluation due to Resident 14's change of condition. The DOR reviewed Resident 14's PT Evaluation history and did not locate a PT Evaluation after noticing Resident 14's decline in right knee ROM on the JMA, dated 5/14/2025. The DOR stated a PT Evaluation should have been completed prior to providing the right knee splint to obtain a baseline measurement, adjust the splint to the right knee, set a goal for the splint wear tolerance, monitor the skin, and train the RNA on applying the splint. During a review of a textbook titled, Guide to Physical Therapist Practice, revised 6/2003, page 2-3, the textbook indicated the physical therapy uses tests and measures to assess the need for splints. The textbook indicated these tests and measures included the fit and safety during the use of the splint. During a review of the facility's policy and procedure (P&P) titled, Joint Mobility Screen, dated 8/2025, the P&P indicated a Joint Mobility Screen would be completed by Rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) for new admissions, readmissions, quarterly, annually, and for residents identified with a functional change. The P&P indicated the physician will be contacted for therapy orders if a PT evaluation was recommended based on the findings from a joint mobility screen. 055157 Page 19 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to ensure to cap (cover) the enteral feeding (a way to deliver liquid nutrition directly into the stomach or small intestine through a soft, flexible tube) tube for one of two sampled residents (Resident 14) reviewed for enteral feeding. This failure had the potential for Resident 14's enteral tube feeding to become contaminated (the presence of unwanted or harmful substances that make something impure, unsafe, or unsuitable for its intended use, often by making it dirty) and increased the risk of infection.Findings:During a review of Resident 14's admission Record, the admission Record indicated the facility originally admitted Resident 14 on 11/18/2022 and readmitted Resident 14 on 1/8/2026 with diagnoses that included esophagitis, unspecified bleeding (the tube connecting your mouth to your stomach is inflamed, irritated, or swollen, causing it to bleed), gastrointestinal bleeding (bleeding in the tube-like system running from the mouth to your butt), aphasia (a disorder that makes it difficult to speak), gastric ulcer (an open, painful sore or raw spot that develops on the inner lining of the stomach), dysphagia (difficulty swallowing), and moderate protein-calorie malnutrition (a condition where the body does not receive enough calories or protein to function properly, leading to noticeable muscle loss, unintentional weight loss, reduced strength, and weakness). During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool) dated 11/10/2025, the MDS indicated Resident 14 usually had the ability to understand others and usually had the ability to make himself understood. During a review for Resident 14's History and Physical (H&P - a doctor's comprehensive check-up that combines your medical background with a physical exam to figure out what is wrong and how to treat it) dated 1/10/2026, the H&P indicated Resident 14 did not have the capacity (ability) to understand and make decisions. During a review for Resident 14's Order Summary Report dated 2/2/2026, the Order Summary Report indicated Resident 14 had physician orders for Jevity (specialized, thick liquid food designed for people who cannot eat normally, often delivered through a feeding tube ) 1.5 cal (calorie - a unit of energy that measures the power your body gets from food and uses for activities like breathing, thinking, and exercising)/ml (milliliter - a metric unit of liquid volume) at 70ml/hr (per hour) for 20 hours via GT (g-tube - a small, soft tube surgically placed through the belly directly into the stomach to deliver food, fluids, and medicine). During a concurrent observation and interview on 2/2/2026 at 10:21 AM with Licensed Vocational Nurse 2 (LVN 2) and the facility's Infection Preventionist (IP), Resident 14's enteral feeding tube that was connected to the enteral feeding bag was observed to be uncapped and exposed to the air. LVN 2 stated the exposed enteral feeding tube could create potential for Resident 14 to become infected. LVN 2 stated Resident 14's entire enteral feeding bag, including the tubing, would need to be changed. The IP stated Resident 14's enteral feeding tube was exposed and could become a source of infection and the enteral feeding bag including the tubing would need to be changed to prevent possible spread of infection. During a concurrent interview and record review on 2/2/2026 at 12:42 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Enteral Feedings - Safety Precautions, dated 1/2025, was reviewed. The DON stated the P&P indicated to ensure the safe administration (to give) of enteral nutrition. The P&P indicated the facility would maintain strict aseptic technique (a set of practices and procedures used to prevent infection by minimizing the presence of harmful germs in a specific area, ensuring they don't enter the body or cause the unwanted presence of harmful, dirty, or impure substances in something that was previously clean) at all times when working with enteral nutrition systems and formulas. The DON stated the facility did not follow their policy. The DON stated leaving Resident 14's enteral tube feeding 055157 Page 20 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0693 uncapped could lead to Resident 14 getting an infection. The DON stated the facility should have followed their enteral feeding P&P. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055157 Page 21 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to: 1. Clarify one of six sampled residents (Resident 31's) physician order for famotidine (a medication used to reduce the amount of acid produced by the stomach) dated 12/24/2025, which did not indicate a frequency (number of times) for taking the medication. 2. Ensure one of six sampled residents (Resident 80's) lidocaine patch (a medication in the form of a patch used to treat inflammation and pain) was available in stock at the facility. These deficient practices had the potential to cause medication errors for Resident 31 and inadequate pain relief for Resident 80 and placed both residents at risk for adverse health consequences such as acid-reflux, and decline in resident's mental, physical, functional or psychosocial status due to inadequate pain management.Findings: 1. During a review of Resident 31's admission Record (a document containing demographic and diagnostic information), dated 2/5/2026, the admission record indicated the facility originally admitted Resident 31 on 12/8/2023 and readmitted on [DATE] with diagnosis that included Gastro-Esophageal Reflux Disease (GERD, a medical condition when stomach acid flows back up into the esophagus and causes heartburn) without esophagitis (inflammation, irritation, or swelling of the esophagus, the tube carrying food from the mouth to the stomach). During a review of Resident 31's Minimum Data Set (MDS - a resident assessment tool), dated 12/3/2025, the MDS indicated Resident 31's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 31 needed supervision or touching assistance from the facility staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, moderate assistance for oral hygiene, upper body dressing and personal hygiene, and maximal assistance for toileting hygiene, lower body dressing and putting on or taking off footwear. During a review of Resident 31's medication reconciliation on 2/5/2026, Resident 31's Order Summary Report (a document containing a summary of all active physician orders), dated 2/4/2026, the order summary report indicated Famotidine Oral Tablet 40 milligram ([mg] a unit of measurement for mass), give 1 tablet by mouth has needed for GERD, order date 12/24/2025, start date 12/24/2025. During a concurrent interview and record review on 2/5/2026 at 1:39 PM with Licensed Vocational Nurse (LVN) 3, Resident 31's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 2/1/2026 to 2/5/2026 was reviewed. LVN 3 stated she did not have Resident 31's famotidine medication bubble pack (sealed card containing individual, daily, or weekly doses of medication in clear, push-through plastic bubbles). LVN 3 stated the MAR from 2/1/2026 to 2/5/2026 indicated famotidine 40 mg was not administered to Resident 31. LVN 3 reviewed the physician's order for famotidine and stated the famotidine was missing the frequency indicating how often the medication had to be given. LVN 3 stated there was a risk that someone could give one dose and someone else could give it again as needed without clear understanding of how to give medication, before meals or after meals or there would be a risk for medication error if given too much too frequently or not given at all. During an interview on 2/5/2026 at 3:24 PM with the Director of Nursing (DON), the DON stated each medication order had to indicate the dose, route, frequency and patient name. The DON stated the famotidine order should have had a frequency, for example, one tablet once a day and if the order did not have a frequency, the facility nurse should have clarified the order with a physician. During a review of the facility's policy and procedure (P&P) titled, Physicians' Medication Orders, dated 1/20/2025, the P&P indicated, Orders for medications must include name and strength of the drug; quantity or specific duration of 055157 Page 22 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few therapy; dosage and frequency of administration; route of administration if other than oral; and reason or problem for which given. 2. During a review of Resident 80's admission Record, dated 2/4/2026, the admission record indicated the facility admitted Resident 80 on 1/29/2026 with diagnoses that included encounter for orthopedic (a term used for musculoskeletal system - bones, joints, ligaments, tendons, and muscles) aftercare following surgical amputation (a surgery to remove all or part of a body appendage), acquired absence of right leg below knee, osteomyelitis (a serious bone infection) of vertebra (bones forming the vertebral column or spine) in humans, thoracic region, Type 2 Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (nerve pain), Type 2 DM with diabetic Chronic Kidney Disease (CKD - a long-term condition involving the gradual loss of kidney function over time) and Stage 3A CKD. During a review of Resident 80's History & Physical (H&P) dated 1/31/2026, the H&P indicated Resident 80 had the capacity to understand and make decisions. During a review of Resident 80's MDS dated [DATE], the MDS indicated Resident 80's cognition was intact. The MDS indicated Resident 80 needed supervision or touching assistance from facility staff for performing ADLs such as eating, moderate assistance for oral hygiene, maximal assistance for toileting hygiene, showering, upper body dressing and personal hygiene, and dependent on facility staff for lower body dressing and putting on or taking off footwear. During a medication reconciliation on 2/5/2026, Resident 80's Order Summary Report, dated 2/4/2026, the order summary report indicated the following physician orders: Lidocaine External Patch 4 percent (% - a unit of strength or potency of the medication), apply to affected area topically every 24 hours as needed for right below the knee amputation (R BKA) site pain, order date 1/29/2026, start date 1/29/2026. Lidocaine External Patch 4%, apply to lower back topically every 24 hours as needed for lower back pain apply 2 patch, order date 1/29/2026, start date 1/30/2026. During a concurrent interview and record review on 2/6/2026 at 1:27 PM with LVN 4 and LVN 5, Resident 80's physician's order instructions and administration details for lidocaine patch 4% and availability of lidocaine patch 4% in stock at facility were reviewed. The administration details on MAR, dated 1/1/2026 to 1/31/2026 and 2/1/2026 to 2/6/2026, indicated there was no documented administration of lidocaine patch 4% as needed for R BKA and lower back pain. LVN 5 stated she did not have Resident 80's lidocaine patch 4% in stock because it was prescribed as needed. LVN 5 stated the facility should have ordered lidocaine 4% patch from the pharmacy and have it available in case Resident 80 needed the lidocaine patch for pain management. LVN 5 stated sorry the facility might have forgotten to request, or the pharmacy did not send them to us. LVN 4 interrupted and stated she (LVN 4) checked in the system and saw a note that indicated the facility requested lidocaine patch 4% from the pharmacy on 1/29/2026 but had not received it yet. LVN 4 stated it had been 8 days since the request, so it was important to follow up with the pharmacy. LVN 4 stated the lidocaine patch would help with local sites and topical pain relief and would be a better option for Resident 80 to try rather than taking opioids (a class of drugs used primarily to reduce moderate to severe pain) with the risk of addiction associated with them. During an interview on 2/6/2026 at 3:03 PM with the DON, the DON stated medications prescribed on an as needed basis should have been in stock at the facility regardless of the type of medication. The DON stated there would be a risk that the resident would not be adequately treated for pain if lidocaine patches were not available in stock. The DON stated the facility nursing staff should have followed up with the pharmacy every day when the lidocaine patch was not in stock. During a review of the facility's P&P titled, Specific Medication Administration Procedures Administration Procedures For All Medications, dated 1/20/2025, the P&P indicated, To administer medications in a safe and effective manner. 055157 Page 23 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper storage, labeling, and/or disposal of medications and supplements in one of two inspected medication carts (Station 2 Medication Cart) and one of one inspected medication room (Station 2 Medication Room), according to manufacturer's specifications and the facility's policy and procedures (P&P), titled Storage of Medications, dated 1/20/2025, Discontinued Medications, dated 1/20/2025 and Hazardous Drug Handling, dated 1/20/2025, by failing to: A. Ensure that three unopened latanoprost (a medication used to treat glaucoma [high eye pressure]) ophthalmic solution vials in Station 2 Medication Cart were stored in the refrigerator or labeled with an open date when they were removed from the refrigerator.One in-use (opened) Humulin R ([generic name - insulin human regular] a type of insulin [a hormone that removes excess sugar from the blood] used to treat high blood glucose) vial in Station 2 Medication Cart was not labeled with an open date.Remove and discard expired in-use bottle of vitamin C (a vitamin used to treat low levels of vitamin C and to support immunity) tablets. Microdot Glucose Gel (a type of glucose gel used in emergency situations to rapidly treat low blood glucose levels), and Boost Breeze (a nutrition drink to support energy and muscle maintenance) nutrition drink from Station 2 Medication Cart.Remove and discard expired insulin aspart (a type of insulin used to treat high blood glucose) prefilled pens from Station 2 Medication Room Refrigerator after the physician order was discontinued and the medication had expired. B. Ensure that the label on the bicalutamide (a medication used to treat progressive prostate cancer) medication card and administration instructions in the electronic medication administration record (eMAR) had instructions for nursing staff to wear gloves and/or follow hazardous drug handling procedures while preparing bicalutamide for administration during medication administration observation for one of six sampled residents (Resident 4). These deficient practices had the potential to result in residents receiving medications and supplements that were discontinued, expired, ineffective and/or toxic due to improper storage, handling and labeling possibly leading to health complications such as glaucoma, hyperglycemia (high blood glucose), hypoglycemia (low blood glucose), lethargy, coma and hospitalization. These deficient practices also had the potential of causing harm to the facility's nursing staff and/or Resident 4 due to unsafe handling of Resident 4's hazardous medication.Findings: A. During a concurrent inspection of the Station 2 Medication Cart and interview on 2/4/2026 at 11:02 AM with the Licensed Vocational Nurse (LVN) 5, the following medication was found stored and labeled in a manner contrary to manufacturer specifications:One sealed vial of latanoprost ophthalmic solution 0.005% was observed with no open date.One opened vial of Humulin R 100 units ([U] a unit of measurement for dose of insulin) / milliliters ([mL] a unit of measurement for volume) insulin was observed with no open date. The manufacturer's product labeling on the vial indicated: in-use (opened) Humulin R vial had to be used within 31 days.One opened bottle of vitamin C 500 milligrams ([mg] a unit of measurement for mass) gluten-free was observed with an expiration date of 01/2026, containing approximately one-quarter of the quantity remaining in the bottle.One Microdot Glucose Gel 40% was observed with an expiration date of 02/2025.One Boost Breeze nutritional drink was observed with an expiration date of 06/2025.LVN 5 stated she (LVN 5) had no idea if the Humulin R was used, but if the seal was opened the Humulin R must have been used. LVN 5 stated the latanoprost eye drops and Humulin R should have had an open date because the medications would only be good for 28 days. LVN 5 stated if the facility nursing staff did not place an open date on Humulin R and latanoprost eye drops then facility 055157 Page 24 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff would not be able to determine latanoprost and Humulin R's expiration dates. LVN 5 stated the latanoprost vials were sealed and should have been stored in the refrigerator when received from the pharmacy but someone who received it probably placed in the medication cart instead. LVN 5 stated there was a risk for negative side effects if the medications were not stored according to the manufacturer's guidelines, for example, if the resident received insulin with an unknown expiration date, there was a risk that insulin would not effectively control blood glucose. LVN 5 stated she did not know side effects related to latanoprost because it was not part of her morning administration, but after some research, LVN 5 stated it would not be safe or effective for the residents to receive latanoprost that did not have an open date to treat glaucoma. During a follow up interview on 2/4/2026 at 11:39 AM with LVN 5, LVN 5 stated the vitamin C should have been removed from the medication cart because it (vitamin C) expired in January 2026. LVN 5 stated vitamin C was a supplement so it would not have a big side effect but still not safe to administer to the facility residents. During a follow up interview on 2/4/2026 at 11:54 AM with LVN 5, LVN 5 stated the Boost Breeze had expired 06/2025 and Microdot Glucose Gel had expired 02/2025 so the Boost Breeze and Microdot Glucose Gel should have been removed from the medication cart. LVN 5 stated the glucose gel was for emergency use to treat hypoglycemia and the expired glucose gel would not have been effective to save a resident's life if they were hypoglycemic (low blood sugar). During a concurrent inspection of the Station 2 Medication Room and interview on 2/4/2026 at 12:16 PM with LVN 1 and Registered Nurse (RN) 2, three unopened insulin aspart flexpen 100 units/mL prefilled pens with an expiration date of 5/31/2025 were found in the medication refrigerator. LVN 1 stated the expired insulin aspart flexpens should have been removed from medication storage before May 2025. LVN 1 stated there was a risk of medication errors if insulin aspart was administered to facility residents. LVN 1 stated the expired insulin would not reduce high blood glucose which would increase the risk for complications such as diabetic retinopathy (diabetes complication damaging retinal blood vessels, potentially leading to blindness), eye problems, kidney problems, hyperglycemia and hospitalization. During an interview on 2/5/2026 at 2:35 PM with the Director of Nursing (DON), the DON stated the facility should have removed the expired medications and supplements from the medication storage areas at least two weeks before they expired. The DON stated it would not be safe to administer expired medications to the facility residents. The DON stated the latanoprost ophthalmic solution should have been stored in the refrigerator to maintain its quality. The DON stated the facility staff was instructed to discard ointments, eye drops and insulin vials within 28 days after opening to ensure that quality and strength were maintained. The DON stated it was important to label latanoprost with an open date and if the latanoprost was not stored in the refrigerator, it would not be safe or effective to be administered to the residents. The DON stated the Humulin R insulin should have had an open date so that the facility's nursing staff could determine the expiration date and discard the medication. The DON stated improper labeling and storage of insulin would negatively affect the insulin's potency (strength) and would not be effective for lowering blood glucose level, causing hyperglycemia (elevated blood sugar) and other serious health consequences such as mental status changes and hospitalization. During an interview on 2/5/2026 at 3:05 PM with the DON, the DON stated insulin aspart flexpen should have been removed from medication storage as soon as it was discontinued and/or expired. The DON stated it was unsafe and there was a risk for accidental administration of expired insulin aspart to facility residents leading to medication errors. B. During a review of Resident 4's admission Record, dated 2/5/2026, the admission record indicated the facility originally admitted Resident 4 on 6/17/2024 and readmitted on [DATE] with diagnoses that included benign prostatic hyperplasia (a noncancerous enlargement of 055157 Page 25 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the prostate that commonly affects men, causing lower urinary tract symptoms like weak stream, frequency, urgency, and incomplete emptying) without lower urinary tract symptoms, and encounter for attention to gastrostomy (a surgical or endoscopic creation of an opening (stoma) into the stomach to insert a feeding tube (G-tube) for delivering nutrition, fluids, or medication directly, or for gastric decompression), essential hypertension (high blood pressure). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 1/16/2026, the MDS indicated Resident 4's cognition (mental action or process of acquiring knowledge and understanding through thought and senses) was left blank. The MDS indicated Resident 4 was dependent on the facility staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as oral hygiene, toileting hygiene, showering upper and lower body dressing, putting on/taking off footwear and personal hygiene and the ability to eat was not attempted due to medical condition or safety concerns. During a concurrent medication administration observation and interview on 2/5/2026 at 9:13 AM with LVN 3, LVN 3 was observed preparing medications for administration via gastrostomy tube. At the time of preparation, LVN 3 was observed wearing a surgical mask and personal eyeglasses. LVN 3 wore a blue surgical gown and one pair of regular gloves before entering Resident 4's room. LVN 3 was observed removing one tablet of bicalutamide 50 mg from the medication bubble pack (sealed card containing individual, daily, or weekly doses of medication in clear, push-through plastic bubbles) without wearing gloves by popping it out into a medicine cup. LVN 3 then placed the bicalutamide 50 mg tablet in a small transparent plastic bag and then crushed the tablet using a crushing device without wearing any gloves. LVN 3 showed medication the bubble pack and eMAR for bicalutamide 50 mg to the surveyor. The pharmacy label indicated, Take one tablet by mouth daily with an additional label indicating directions changed refer to chart, neither the pharmacy label nor the eMAR indicated to wear gloves or to follow hazardous drugs handling procedures. LVN 3 stated the pharmacy label indicated to give the medication by mouth but the order was changed in eMAR to indicate by g-tube. LVN 3 was then observed removing the blue gloves and resumed crushing the remainder of Resident 4's medications. During a review of Resident 4's Order Summary Report dated 2/4/2026, the order summary report indicated Casodex ([generic name bicalutamide]) 50 mg, give 1 tablet via G-tube one time a day for prostate cancer (CA), order date 1/23/2026, start date 1/24/2026. During an interview on 2/5/2026 at 1:18 PM with LVN 3, LVN 3 stated she did not see instructions to wear gloves or double gloves when administering bicalutamide. LVN 3 stated she would need to research to check what conditions bicalutamide was given to treat. LVN 3 then stated she found in her research that she had to be careful when handling bicalutamide because these meds had a risk for baby or toxicity to babies if handled or touched by women who were young, pregnant or those with childbearing age. LVN 3 stated she needed to inform pharmacy because the bicalutamide administration instructions did not indicate it was a hazardous drug on the pharmacy label. LVN 3 stated there was a risk for skin irritation, respiratory problems, or women of childbearing age or immunocompromised could have issues with neonatal toxicity or could affect fetus. LVN 3 stated there was a risk of breathing in the particles while preparing Resident 4's bicalutamide so it was important to wear a N95 mask (a mask that is NIOSHapproved disposable respirators designed to filter at least 95% of airborne particles, offering superior protection against viruses, bacteria, and dust compared to cloth masks). During an interview on 2/5/2026 at 3:10 PM with the DON, the DON stated she needed to do some research and look on WebMD (a medical search engine for drug information) and google to learn more about bicalutamide. The DON stated bicalutamide was a nonsteroidal, anti-cancer medication. The DON stated hazardous drugs could be very strong and toxic so should not have been handled 055157 Page 26 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with bare hands. The DON stated healthcare personnel could get gastrointestinal (stomach/digestive) side effects. The DON stated, pregnant women should follow special precautions, handle carefully, wear gloves and should not have had direct contact. The DON stated there would be a risk for the bicalutamide to be absorbed via skin for the nurse and could also pose a safety risk for the resident if the resident touched the bicalutamide. During a review of the facility's P&P titled Storage of Medications dated 1/20/2025, the P&P indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The P&P indicated, Temperature - Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 F (2 C) and 46 F (8 C) with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. The P&P indicated, Certain medications or package types, such as intravenous (IV) solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. The P&P indicated, When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) the nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. (Note: the best stickers. notation line). The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date or regulations/guidelines require different dating (See. dates). The P&P indicated, All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. During a review of the facility's P&P titled Discontinued Medications dated 1/20/2025, the P&P indicated When medications are discontinued by the prescriber or the resident. are marked as discontinued and stored in a secure and separate area from the active supply, marked discontinued . until destroyed. The P&P indicated, Medications are removed from the medication cart or active supply immediately upon receipt of an order to discontinue (to avoid inadvertent administration). During a review of the facility's P&P titled United States Pharmacopeia (USP) Chapter <800>: Hazardous Drug dated 1/20/2025, the P&P indicated USP General Chapter <800> provides standards for safe handling hazardous drugs to minimize the risk of exposure to healthcare personnel, patients and the environment.Facilities are recommended to check with local and state regulatory agencies to verify requirements for Hazardous Drug Handling. The National Institute for Occupational Safety and Health (NIOSH) considers a drug to be hazardous if it exhibits one or more of the following characteristics in humans or animals: carcinogenicity, teratogenicity or developmental toxicity, reproductive toxicity, organ toxicity at low doses, genotoxicity. The P&P indicated, The facility must develop and maintain a health and safety management system which shall, at a minimum, include the following: A. List of Hazardous Drugs (HDs), B Facility and engineering controls; . E. Proper use of appropriate Personal Protective Equipment (PPE); and F. Policies for HD waste segregation and disposal. This policy applies to all healthcare personnel who handle HD preparations and all entities that store, prepare, transport, or administer HDs. The P&P indicated a list of Hazardous Medications - Quick Safety Guide with Most Common Hazardous Medications (Skilled Nursing Facility [SNF] / Long-Term Care [LTC]), the list indicated but not limited to Casodex (Bicalutamide) with the key risk of reproductive/hormonal toxicity with the instructions of ‘crushing not allowed', and Proscar (Finasteride), with the key risk of teratogenic (pregnancy risk) with instructions of ‘crushing not allowed'. The Hazardous Medications - Quick Safety Guide indicated, Safe Handling Guidelines that indicated to always wear chemo-rated gloves when handling hazardous medications. Do NOT crush, split, or open hazardous tablets or capsules unless 055157 Page 27 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0761 Level of Harm - Minimal harm or potential for actual harm pharmacy-approved containment is used. Avoid direct contact with powder, residue or bodily fluids when applicable. If swallowing difficulty exists, request alternative formulations or therapies. Reminder: When in doubt, treat the medication as hazardous and consult pharmacy before altering dosage form. Residents Affected - Some 055157 Page 28 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1.One expired medium container of tomato sauce with use by date (the last day the manufacturer guarantees the food's peak quality, flavor, and nutrient value) of 1/29/26 was stored in the facility's walk-in refrigerator. 2. One package of beef patty was stored in the facility's walk-in refrigerator to thaw with no date (indicates when a frozen food item was moved to the refrigerator to thaw). 3. The blade of the can opener located in the facility's food preparation area was worn and dented and had dried and sticky brown residue on it. 4. Apple sauce was stored at room temperature on two of two sampled medication carts in Nurses' station 2 (medication cart 1and 2) for longer than 4 hours. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 69 out of 73 residents who received food from the facility kitchen. Findings: 1. During an observation in the kitchen on 2/2/2026 at 8:00AM, a medium container of tomato sauce with a use by date of 1/29/2026 was observed stored in the walk-in refrigerator. During a concurrent observation with the [NAME] 1 on 2/2/2026 at 8:10AM cook1 stated the tomato sauce should have been discarded to make sure kitchen staff only cooked with quality foods. Cook1 stated expired foods could cause sickness in residents who received food from the facility kitchen. 2. During an observation in the facility's walk-in refrigerator on 2/2/2026 at 8:15AM there was one package of raw ground beef stored with no date. During a concurrent observation and interview with Cook1 on 2/2/2026 at 8:15AM, Cook1 stated the beef was to be used on the date of the observation (2/2/2026) but the beef should have had a thaw date to alert kitchen staff when to prepare the beef. Cook1 verified with a phone call that the previous day (2/1/2026) staff removed the raw ground beef from the freezer to thaw and forgot to label and date. During a concurrent observation and interview with the Dietary Supervisor (DS) on 2/2/2026 at 8:30AM, the DS stated food was discarded on use by date and everything had to be labeled and dated to make sure it was used or discarded before the food expired. The DS was then observed discarding the raw thawed ground beef and the tomato sauce. During a review of facility's policy and procedure (P&P) titled Procedure for refrigerated storage dated 2023, the P&P indicated Frozen food should be left in a refrigerator to thaw. Once thawed uncooked meat is to be used within 2 days. Leftovers will be covered, labeled and dated. Individual packages of refrigerator or frozen food taken from the original packing box need to be labeled and dated. During a review of facility's policy and procedure (P&P) titled, Thawing of meats dated 2023, the P&P indicated thawing meat properly can be done in these four ways: 1) in a refrigerator at 41 F or colder. Allow 2 to 3 days to defrost. 3. During an observation in the kitchen food preparation area on 2/2/2026 at 8:30AM, one can opener's blade was observed to be worn out and dirty. The blade was not smooth to touch, stained, and covered with sticky and dry brown colored residue. During a concurrent observation and interview with the DS on 2/2/2026 at 8:30AM, the DS observed the can opener and verified that there was sticky brown residue, and the blade was worn out. The DS stated the can opener needed to be washed. The DS stated the blade had to be replaced to prevent cross contamination of canned food. During a review of the facility's policy and procedures (P&P) titled Can opener and base dated 2023, the P&P indicated proper sanitation and maintenance of the can opener is important to sanitary food preparation. Metal shavings and shredding can result from a dull cutting blade. The can opener must be thoroughly cleaned each work shift. During a review of the 2022 U.S. Food and Drug Administration Food Code titled Good Repair and proper Adjustment Code # 4-501.11(C), the code indicated Cutting or piercing parts of 055157 Page 29 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened. During a review of 2022 Food Code titled, Can Openers Code# 4-202.15, the code indicated Once can openers become pitted or the surface in any way becomes uncleanable, they must be replaced because they can no longer be adequately cleaned and sanitized. 4. During an observation in nurses' station 2 of medication cart 1 on 2/2/2026 at 11:30AM, a small plate of apple sauce with a date of 2/2/2026 was observed to be stored on the nurse's medication cart at room temperature and not set on ice. During a concurrent observation in nurses' station 2 of medication cart 1 and interview with LVN3 on 2/2/2026 at 11:30AM, LVN 3 stated the apple sauce was used to mix with crushed medications for residents. LVN 3 stated the apple sauce was delivered from the kitchen that morning (2/2/2026) at 7am. LVN 3 stated the plates of apple sauce did not come set on ice. During a concurrent observation in nurses' station 2 of medication cart 2 and interview with LVN2 on 2/2/2026 at 11:40AM, LVN2 was observed administering medications to residents. Medication cart 2 contained a plate of apple sauce. LVN2 stated the apple sauce was delivered from kitchen that morning (2/2/2026) at 7am and the apple sauce was not on ice. LVN2 stated the apple sauce had been used for longer than 4 hours. During a concurrent observation in nurses' station 2 of medication cart 2 and interview with the DS on 2/4/2026 at 12:30PM, the DS stated apple sauce was delivered from the kitchen to the nurse's station in the mornings and afternoons. The DS stated the apple sauce should have been on ice for the duration of the medication administration to prevent the apple sauce from going bad. The DON verified that there was a plate of apple sauce on medication cart 2 and the apple sauce was not on ice. The DON stated all snacks and apple sauce from kitchen had to be delivered on ice. During a review of the manufacturer's instructions for storage located on the label of the canned apple sauce, the label indicated to Refrigerate in separate container any unused portions of the applesauce. 055157 Page 30 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner, when two of two trash bins were overfilled with the lids open. This deficient practice had the potential for harborage (accumulation of garbage, waste, debris, or materials that provide shelter, protection, food, or a breeding ground for pests such as rodents [rats, mice], insects, and other vermin) and feeding of pests and/or animals.Findings: During an observation in the main dumpster area located outside of the kitchen back door on 2/2/2026 at 11:00AM; there were two large trash bins that were overfilled and the trash bins were pushed back against a wall with the lids open. During a concurrent observation and interview with the Dietary Supervisor (DS), housekeeping supervisor (HS), and Central Supply manager (CM) on 2/2/2026 at 11:15AM. The DS stated the trash should have been covered to not attract pests to the area. The HS stated the trash bins were pushed back against a wall and the lids were not accessible to close. The CM stated the trash was picked up every day except Sundays and Tuesday. The CM stated the lids had to be closed always to maintain a clean area because all the deliveries for the facility passed through the trash area. During an interview with the Maintenance Supervisor (MS) on 2/4/2026 at 1:00PM, the MS stated the lids had to be closed always to prevent pests from going in the trash and eating the trash. The MS stated the lids were pushed all the way back to the wall and facility staff could not close the lids. A review of facility's policy titled Garbage and rubbish disposal (dated 2023) the P&P indicated, all garbage and rubbish containers shall be provided with tight fitting lids or covers and must be kept covered when stored or not in continuous use. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. A review of Food and Drug Administration (FDA) Food Code 2022 dated 1/18/2023, code number 5-501.113 titled Covering receptacles, indicated: receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids or doors if kept outside the establishment. The Food Code also indicated under code number 5-501.110 titled Storing Refuse, Recyclables, and Returnable indicated refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. Residents Affected - Some 055157 Page 31 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain infection control measures necessary to prevent the spread of infections by failing to ensure the staff wore full personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), including use of a face mask to cover both nose and mouth, during influenza ([flu] illness that infect the nose, throat, and lungs, causing sudden fever, cough, sore throat, body aches, and fatigue) season in accordance with the facility's policy and procedures titled Respiratory Virus Prevention and Control Plan, updated on 11/21/2025. These deficient practices had the potential to result in the spread of disease and illness throughout the facility, which could result in severe respiratory illness, hospitalization and/or death.Findings: During an interview on 2/5/2026 at 8:24 a.m. with the Infection Prevention Nurse (IPN), the IPN stated facility staff needed to wear face masks while inside the facility due to the current flu and Coronavirus disease 2019 ([COVID-19] a highly contagious viral disease that can cause respiratory illness) season. During an observation on 2/5/2026 at 11:49 a.m. Certified Nursing Assistant 1 (CNA 1) was observed sitting on a seat in a resident room not wearing a face mask. During a concurrent observation and interview on 2/5/2026 at 12:01 p.m. in the same room, CNA 1 was observed sitting on a seat without wearing a face mask. CNA 1 stated a different CNA (unidentified) was assigned to the room and was at lunch. CNA 1 was assigned to three other resident rooms. CNA 1 stated she came back from lunch at 11:30 a.m. and went straight to the room to relieve the other CNA. CNA 1 stated the staff were supposed to wear a face mask while inside the facility to protect both the staff and residents from the flu. During an interview on 2/5/2026 at 1:00 p.m. with the IPN, the IPN stated the staff were required to wear masks inside the facility to protect the residents from respiratory (affecting the lung) viruses. The IPN stated staff should definitely wear a face mask while inside resident rooms. During an interview on 2/5/2026 at 1:36 p.m. with the Director of Nursing (DON), the DON stated the facility required the staff to wear face masks during flu season. The DON stated the residents, and staff could be exposed to viruses, bacteria, and anything that could be transmitted from one person to another without wearing a face mask. During a concurrent interview and record review on 2/5/2026 at 2:46 p.m. with the IPN, the facility's P&P titled, Respiratory Virus Prevention and Control Plan, updated 11/21/2025, was reviewed. The IPN stated the number of individuals infected with the flu was increasing in Los Angeles County. The IPN stated the facility staff had to wear a face mask while in the facility due to the increased community transmission of the flu. The IPN stated the facility staff received a recent in-service education about the facility's respiratory virus prevention and control plan. During a review of the facility's in-service attendance log titled, Respiratory Virus Prevention & Control Plan, dated 1/16/2026, the in-service indicated the facility residents were at increased risk for severe disease, hospitalization, death, and outbreaks caused by COVID-19, influenza, and other respiratory viruses. The in-service indicated the use of face masks or respirators for source control of respiratory infections to prevent healthcare professionals from infecting residents and other staff with respiratory viruses. During a review of the facility's policy and procedure (P&P) titled, Respiratory Virus Prevention and Control Plan, updated 11/21/2025, the P&P indicated health care professionals would use face masks or respirators (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) for source control of respiratory infections. The P&P indicated the facility would implement source control masking during period of increased community transmission of respiratory viruses. Residents Affected - Few 055157 Page 32 of 33 055157 02/06/2026 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0911 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four of 38 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) met the requirement of no more than four beds per room. This failure had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents who resided in room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER].Findings:During a review of the facility's Room Variance Waiver Request dated 2/4/2026, the Room Variance Waiver Request indicated the facility requested a room variance waiver for room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. The Room Variance Waiver Request indicated there was enough space to provide each resident's care, dignity, privacy, and that the rooms were in accordance with the special needs of residents. The Room Variance Waiver Request indicated the rooms were in accordance with the special needs of residents and would not have an adverse effect (unwanted result) on the residents' health and safety or impede with the ability of any resident in the rooms to attain his or her highest practicable well-being. The Room Variance Waiver Request indicated the facility would ensure that all measures would be taken to assure the comfort of each resident in room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. During an observation on 2/4/2026 at 1:36 PM room [ROOM NUMBER] appeared to have enough space for therapy and nursing services to be provided to the residents (in general) in the room. During an interview on 2/4/2026 at 1:38 PM with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated there was enough space in room [ROOM NUMBER] for therapy, to maneuver (move around), and to provide residents (in general) with nursing services. During an observation on 2/4/2026 at 1:42 PM room [ROOM NUMBER] was observed to have enough space for therapy, resident activity, and nursing services for the residents (in general) in the room. During a concurrent observation and interview on 2/4/2026 at 1:47 PM with Certified Nursing Assistant 1 (CNA 1) the space in room [ROOM NUMBER] was observed to have enough space for therapy, resident activity, and nursing services. CNA 1 stated there was enough space to perform therapy and for the staff to provide residents in the room with services. During an observation and interview on 2/4/2026 at 1:55 PM facility staff (in general) were observed assisting residents (in general) in room [ROOM NUMBER]. The staff had enough room to provide services for the residents (in general). During an interview on 2/4/2026 at 1:57 PM with Resident 13, Resident 13 stated he (Resident 13) did not have any complaints about the size of room [ROOM NUMBER] with five beds. During a review of the facility's policy and procedure (P&P) titled, Resident Room Size, dated 1/2025, indicated the residents would have at a minimum of 80 square feet of living space and no more than 4 residents to a room. Any room not meeting the requirements would require the facility to request a room waiver from CDPH annually (every year). The Department is recommending continuation of the room waiver request. 055157 Page 33 of 33