Other·February 12, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflect the findings of the Department of Public Health during the annual Recertification Survey. Representing the Department of Public Health: Surveyor ID No. 38601, RN, HFEN Surveyor ID No. 38548, RN, HFEN Surveyor ID No. 36923, RN, HFEN Surveyor ID No. 36627, RN, HFEN Total Population: 108 Sample Size: 35 Highest Severity and Scope: G

F578 SS=D Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 02/16/2018 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 1 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed with the residents and/or responsible parties for two (2) out of the 35 sampled residents (Residents 31 and 41). This deficient practice violated the residents' and/or the representatives' right to be fully FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 2 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE informed of the option to formulate their advance directives. Findings: a. A review of Resident 31's Admission Record indicated the resident was originally admitted to the facility on July 4, 2017, and was readmitted on September 12, 2017, with diagnoses of, but not limited to, generalized muscle weakness, paraplegia (paralysis of the legs and lower body typically caused by spinal injury or disease), chronic pulmonary edema (condition caused by excess fluid in the lungs), hypertension (HTN - elevated blood pressure), and atrial fibrillation (an abnormal heart rhythm characterized by rapid and irregular beating). A review of Resident 31's Quarterly Minimum Data Set (MDS- a standardized assessment and screening tool) dated October 10, 2017, indicated the resident has intact cognition, is able to make self understood, and is able to understand others. The tool indicated the resident needs limited assistance with eating; needs extensive assistance with bed mobility, dressing, toilet use and personal hygiene; and is totally dependent with transfers, locomotion, and bathing. A review of Resident 31's Physician Orders for Life-Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST form is not an advance directive), prepared on July 20, 2017, did not indicate that advance directives were discussed. During an interview with Social Services FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 3 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Designee (SSD), on December 28, 2017 at 9:06 a.m., when asked about Resident 31's information if advance directives were discussed, SSD stated they did not do that and there's no documentation that the formulation of advance directives was offered. SSD stated they will be working on this for all residents. A review of the facility's undated policies and procedures titled "Advance Directives," indicated prior to admission of a resident to the facility, the Social Services Director or designee will provide information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. Inquiries concerning advance directives should be referred to the Administrator, Director of Nursing Services, and/or to the Social Services Director. b. A review of Resident 41's Admission Record indicated the resident was originally admitted to the facility on October 12, 2017. A review of Resident 41's Order Summary Report indicated the resident has diagnoses of, but not limited to, history of transient ischemic attack (TIA - also called a mini-stroke, is a neurological event with the signs and symptoms of a stroke [the sudden death of brain cells in a localized area due to inadequate blood flow], but which go away within a short period of time), cerebral infarction (a brain lesion in which a cluster of brain cells die when they don't get enough blood), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 4 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hypertension (elevated blood pressure), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Resident 41's Admission Minimum Data Set (MDS- a standardized assessment and screening tool) dated October 19, 2017, indicated the resident has intact cognition, is able to make self understood, and is able to understand others. The tool indicated the resident needs limited assistance with walking, toilet use and personal hygiene and needs extensive assistance with bed mobility, transfers, locomotion, dressing, and eating. A review of Resident 41's Physician Orders for Life-Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST form is not an advance directive.) prepared on October 13, 2017 by Director of Social Services (DSS), did not indicate if the advance directives were available and reviewed, if the advance directives were not available, or if there were no advance directives. During an interview with DSS on December 26, 2017 at 9:49 a.m., DSS stated Resident 41 does not have advance directives. When asked to show the documentation showing advance directives were explained to Resident 41's representative, DSS stated there was none. During an interview with Licensed Vocational Nurse 1 (LVN 1), on December 28, 2017 at 8:52 a.m., while LVN 1 reviewed Resident 41's records, LVN 1 stated there is no form titled "Acknowledgment of Receipt Advance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 5 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Directive/Medical Treatment Decisions" for the resident to show that the facility has offered and given the option about advance directives to Resident 41 and/or to the resident's legally recognized decision-maker. A review of the facility's undated policies and procedures titled "Advance Directives," indicated prior to admission of a resident to the facility, the Social Services Director or designee will provide information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. Should the resident indicate that he/she has issued advance directives about his or her care and treatment, documentation must be recorded in the medical record of such directive and a copy of such directive must be included in the resident's medical record.

F583 SS=D Personal Privacy/Confidentiality of Records CFR(s): 483.10(h)(1)-(3)(i)(ii)

F583 01/17/2018 §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the residents right to personal privacy, including FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 6 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the Restorative Nursing Assistant (RNA) failed to maintain one of 35 sampled residents (Resident 75) right to privacy by failing to pull the privacy curtain during range of motion exercise. This deficient practice violated Resident 75's right to privacy. Findings: A review of Resident 75's admission record indicated an initial admission to the facility on January 9, 2012 and the most recent readmission was on November 11, 2013, with diagnoses including high blood pressure and acquired absence of left and right legs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 7 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 75's Minimum Data Set (MDS - a standardized comprehensive assessment and care planning tool) dated November 16, 2017, indicated the resident was moderate impairment of cognitive skills for daily decision making. The resident required extensive assistance with one person physical assistance with bed mobility, dressing, toilet use, and personal hygiene. On December 27, 2017 at 10:35 a.m., during an observation, RNA 3 was observed performing PROM exercise to Resident 75's hip and left hand fingers. RNA 3 did not pull the privacy curtain to provide Resident 75 full visual privacy. During the ROM exercise, Resident 75's roommate was sitting in his wheelchair and was sometimes looking at RNA 3 and Resident 75. On December 27, 2017 at 10:55 a.m., during an interview, RNA 3 stated she forgot to pull the privacy curtain. RNA 3 stated she should have pulled the curtain to maintain Resident 75's privacy during ROM exercise. A review of the facility's undated policy titled "Personal Privacy" indicated the residents have right to personal privacy. Pulling the privacy curtain is a way to preserve privacy. On December 28, 2017 at 9:22 a.m., during an interview, the Director of Nursing (DON) stated the RNA was to maintain the resident's privacy during the procedure by pulling the privacy curtain or lock the door.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 01/17/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 8 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 9 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of 35 sample residents (Resident 52, Resident 78) by: 1. Failing to assess and develop individualized interventions to address the refusal of blood sugar monitoring and/or insulin (a medication to control blood sugar level) for Resident 52. 2. Failing to implement the care plan intervention to observe aspiration (breathing in a foreign object) precautions for (Resident 78). These deficient practices had the potential to result in complications associated with uncontrolled blood sugar (eye problems and kidney problems) for Resident 52, and to result in Resident 78 who has a history of pneumonia (lung inflammation), coughing and choking while eating and can lead to pneumonia. Findings: a. A review of the admission record indicated Resident 52 was admitted to the facility on January 20, 2015 and readmitted on April 8, 2016, with diagnoses that included diabetes (high blood sugar), hypertension (high blood pressure), and benign prostatic hyperplasia (BPH- prostate gland enlargement). A review of Resident 52's History and Physical report dated April 6, 2017, indicated the resident had the capacity to understand and make decisions. A review of Resident 52's laboratory test results indicated the following: 1. Hemoglobin A1C (a test that measures a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 10 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE person's average blood glucose level over the past 2 to 3 months) of 6.9 percent (reference range 4.0 to 6.0 percent), dated December 21, 2016. 2. Hemoglobin A1C of 7.0 percent, dated March 23, 2017. 3. Hemoglobin A1C of 7.3 percent, dated June 21, 2017. 4. Hemoglobin A1C of 7.3 percent, dated September 20, 2017. 5. Hemoglobin A1C of 7.3 percent, dated December 20, 2017. A review of Resident 52's physician orders dated October 25, 2017, indicated to give Insulin Aspart solution (used to treat high blood sugar), inject subcutaneously (under the skin) two times a day as per sliding scale (refers to the progressive increase in pre-meal or nighttime insulin doses and is based on fingerstick blood sugar test levels done at set intervals): if blood sugar (mg/dl) zero to 60 mg/dl = 0 unit; if blood sugar (BS) less than 59, give 1 ampule (an airtight container of solution) of dextrose (a simple sugar) 50 via intravenous (administered into a vein) push (a rapid injection) and call the physician; BS: 60 to 200 mg/dl = 0 unit; BS: 201 to 250 mg/dl = 3 units, BS: 251 to 300 mg/dl = 4 units, BS: 301 to 350 mg/dl = 6 units, BS: 351 to 400 mg/dl = 9 units, and BS greater than 401 mg/dl call physician. A review of Resident 52's revised care plan dated November 10, 2017, indicated the resident was at risk for compromised condition related to non-compliance behavior, episode of refusal to take medication. The goal indicated Resident 52 will maintain stable condition daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 11 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for 90 days. The care plan interventions indicated to approach the resident calmly and unhurriedly, explain the risks and negative consequences and importance of medications, notify the family and physician, and respect the resident's rights to refuse medication. A review of Resident 52's Medication Administration Record (MAR) indicated the following: 1. Resident 52 refused Licensed Vocational Nurse 5 (LVN 5) to check his morning (6:30 a.m.) blood sugar 30 out of 31 days in January 2017. 2. Resident 52 refused LVN 5 to check his morning blood sugar 26 out of 28 days in February 2017. 3. Resident 52 refused LVN 5 to check his morning blood sugar 25 out of 31 days in March 2017. 4. Resident 52 refused LVN 5 to check his morning blood sugar seven out of 30 days in April 2017. 5. Resident 52 refused LVN 5 to check his morning blood sugar 14 out of 31 days in August 2017. 6. Resident 52 refused LVN 5 to check his morning blood sugar 21 out of 30 days in September 2017. 7. Resident 52 refused LVN 5 to check his morning blood sugar 23 out of 31 days in October 2017. 8. Resident 52 refused LVN 5 to check his morning blood sugar 22 out of 30 days in November 2017. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 12 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 9. Resident 52 refused LVN 5 to check his morning blood sugar 20 out of 28 days in December 2017. On December 28, 2017 at 11:43 a.m. during an interview, LVN 1 stated she reviewed Resident 52's nursing notes and interdisciplinary team (IDT - a coordinated group of experts from several different fields who work together toward a common resident goal) meeting notes and could not find documented evidence the nursing staff assessed the resident to identify the cause of his refusal for blood sugar monitoring. LVN 1 stated the pharmacist consultant and the nursing staff were responsible for monitoring resident's MAR to ensure there were no irregularities. LVN 1 stated she could not explain why Resident 52 was allowing other licensed nursing staff to check his blood sugar and refusing LVN 5 to check his blood sugar. LVN 1 stated she could not find documented evidence the physician was notified regarding Resident 52's refusal for blood sugar monitoring. On December 28, 2017 at 03:05 p.m. during an observation, Resident 52 was sitting in his wheelchair. Resident 52 was awake, alert, and oriented to person, place and time. During a concurrent interview in the presence of LVN 6 as the interpreter, Resident 52 stated he had his blood sugar checked and received insulin twice a day: in the morning (6:30 a.m.) and evening (4:30 p.m.). Resident 52 stated he did not have any concern regarding LVN 5. Resident 52 also stated he never refused to have his blood checked, and/or never refused to receive insulin. When asked for the cause of his refusal as indicated in the MAR, Resident 52 got irritated, started raising his voice and stated he never refused insulin or blood sugar check. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 13 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's undated policy titled "Comprehensive Person-Centered Care Planning Process" indicated the purpose of the policy was to develop and implement a baseline and comprehensive person-centered care planning for each resident which meets the standards of quality of care in a timely manner and provided by qualified professionals who are culturally competent. b. A review of Resident 78's Admission Record indicated the resident was originally admitted to the facility on July 31, 2012 and readmitted on January 6, 2017, with a diagnoses of, but not limited to, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and generalized muscle weakness. A review of Resident 78's History and Physical Examination signed by the resident's physician on January 1, 2017, indicated the resident was transferred from the acute hospital after treatment of pneumonia (lung inflammation caused by bacterial or viral infection). The record also indicated Resident 78 has diagnosis of, but not limited to, congestive heart failure (heart muscle is weakened and cannot pump enough blood to meet the body's needs for blood and oxygen). A review of Resident 78's Quarterly Minimum Data Set (MDS- a standardized assessment and screening tool) dated November 14, 2017, indicated the resident has severe cognitive impairment, is able to make self understood, and is able to understand others. The tool indicated the resident needs limited assistance with eating and toilet use and needs extensive assistance with bed mobility, transfers, walking in corridor, dressing, and personal hygiene. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 14 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 78's Order Summary Report indicated a physician's order dated May 26, 2017, for controlled carbohydrates diet (carbohydrate intake is either limited or set at a particular value usually used to help stabilize blood sugar levels), mechanical soft texture (modified in consistency and texture by cooking, grinding, chopping, mincing, or mashing), finely chopped diet, aspiration precautions (measures taken to prevent a person from aspirating or choking), fortified diet (foods such as cream, butter, milk, and milk powder are added to the meals to increase the caloric and nutrient content), and large portion at breakfast. During lunch meal observation in the Dining Room on December 20, 2017 at 12:27 p.m., and a concurrent interview with Resident 78, Resident 78 was eating her lunch independently. Resident 78 was seated on a chair with her bottom on the front edge of the seat. The table height was up to Resident 78's chest. Resident 78's food tray was situated greater than the resident's arms length away from her, and was reaching for her food. When the resident was asked about the height of the table, Resident 78 answered in her own language, that the table was too high for her. Restorative Nursing Assistant 1 (RNA 1) assisted in translating for the resident. During an interview with the Registered Dietician (RD) on December 26, 2017 at 3:51 p.m., the RD stated the dietary department follows the speech therapy recommendations about the residents' diets. During an interview with the Speech Language Pathologist (SLP) on December 26, 2017 at 4:12 p.m., SLP stated Resident 78 was admitted to the facility with difficulty of chewing, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 15 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE which is a part of the oral (relating to the mouth) phase of swallowing. SLP stated that upon initial SLP (ST - Speech Therapy) evaluation, the resident was on the safest diet which is the current diet Resident 78 is on. SLP stated Resident 78's treatment had been completed for possible advanced diet but the resident was not able to safely tolerate the higher level of diet; hence, the resident was discharged from SLP treatment with recommendations. SLP stated the following recommendations were given to the Nursing Department: continue with the recommended diet texture and to observe general safe swallowing precautions which are to sit upright when eating, to take small bites slowly, and to reduce distractions. SLP stated she informed the Nursing Supervisor of the recommendations upon a resident's discharge from Speech Therapy. SLP stated that if necessary, she gives the Nursing Department the written instructions, but in Resident 78's case, the recommendation was to observe safe swallowing precautions. During a review of Resident 78's Speech Therapy Discharge Summary signed by SLP on January 16, 2017, the recommendations included (but not limited to) to provide occasional supervision for oral intake and to observe general swallow techniques/precautions, upright posture during meals, and upright posture for greater than (>) 30 minutes after meals. During a review of Resident 78's care plan addressing the resident's weight loss, one intervention initiated on December 7, 2017, indicated the resident was to have a mechanical soft texture finely chopped diet, aspiration precautions, and fortified diet. The care plan did not include the recommendations by the SLP to observe safe swallowing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 16 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE precautions. A review of the facility's undated policies and procedures titled "Aspiration Precautions Policy & Procedure," indicated the following when placing a patient on aspiration precautions: 1. Good oral care before and after meals. 2. Sit up at 90 degree angle in bed or chair for meals, or follow specific positioning guidelines per the Speech Language Pathologist (SLP). Stay up for 30 minutes after meal. Then 45 degree angle at all times. The policies and procedures also indicated to follow level of supervision recommendations for mealtime (determined by staff and/or SLP). It indicated close supervision as frequent checking and cueing the patient to use strategies/maneuvers. The policies and procedures indicated distant supervision as checking on patient at least 2-3 times or have the patient eat near the nurses' station).

F658 SS=E Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 01/17/2018 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the licensed nursing staff failed to meet professional standards of quality for medication administration for six (6) of 35 sample residents (Residents 41, 78, 102, 6, 88 and 35) by: 1. Failing to ensure the insulin (a hormone that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 17 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE works by lowering levels of glucose [sugar] in the blood) injection sites were rotated when administered to four (4) out of the 35 sampled residents (Residents 41, 78, 102 and 6) who received insulin injections. 2. Failing to administer Metoprolol (a medication used to treat high blood pressure, chest pain, and heart failure) (Resident 88) and Doxazosin Mesylate Tablet (a medication used to treat high blood pressure) (Resident 35) based on the parameters (fixed limits) set on the physician's written order. These deficient practices had the potential for injection site reactions such as pain, redness, itching, hives (red and sometimes itchy bumps on the skin), swelling, inflammation, lipodystrophy (defect in the breaking down or building up of fat below the surface of the skin, resulting in lumps or small dents in the skin surface which may be caused by repeated injections of insulin in the same spot), lipoatrophy (wasting of fat under the skin which can be unsightly), and lipohypertrophy (buildup of fat under the skin which can slow the absorption of insulin) that may result in ineffective management of the residents' diabetes mellitus (DM - high blood sugar) for Residents 41, 78, 102, and 6) and had the potential to result in unintended consequences of the management of blood pressure such as hypotension (abnormally low blood pressure and can lead to dizziness and falls) for Resident 88 and 35. Findings: a. A review of Resident 41's Admission Record indicated the resident was originally admitted to the facility on October 12, 2017, with a diagnosis of, but not limited to, type 2 diabetes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 18 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE mellitus (DM - high blood sugar). A review of Resident 41's Admission Minimum Data Set (MDS- a standardized assessment and screening tool) dated October 19, 2017, indicated the resident has intact cognition, is able to make self understood, and is able to understand others. The tool indicated the resident needs limited assistance with walking, toilet use and personal hygiene and needs extensive assistance with bed mobility, transfers, locomotion, dressing, and eating. A review of Resident 41's Order Summary Report indicated a physician's order dated October 12, 2017, to administer Lantus Insulin (Insulin Glargine - lowers the level of glucose [sugar] in the blood by helping glucose enter the body's cells) inject 60 units subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) in the evening for DM. Another physician's order dated October 12, 2017 indicated to inject Novolin R (Insulin Regular - short-acting insulin used to lower blood glucose [sugar] levels) as per sliding scale coverage (progressive increase in the insulin dose, based on predefined blood glucose ranges) subcutaneously two times a day for DM. During a record review of Resident 41's Location of Administration Reports (injection site records) for Lantus and Novolin R for December 2017, and a concurrent interview with Registered Nurse 1 (RN 1) on December 20, 2017 at 11:56 a.m., the records indicated the following findings: 1. Lantus was administered to Resident 41's right lower quadrant (RLQ) abdomen on December 4, 2017 and December 5, 2017. 2. Lantus was administered to Resident 41's right upper quadrant (RUQ) abdomen from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 19 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE December 6, 2017 to December 8, 2017. 3. Lantus was administered to Resident 41's left upper quadrant (LUQ) abdomen on December 9, 2017 and December 10, 2017. 4. Lantus was administered to Resident 41's right lower quadrant (RLQ) abdomen on December 11, 2017 and December 12, 2017. 5. Lantus was administered to Resident 41's right lower quadrant (RLQ) abdomen from December 14, 2017 to December 16, 2017. 6. Lantus was administered to Resident 41's right lower quadrant (RLQ) abdomen on December 20, 2017 and December 21, 2017. 7. Novolin R was administered to Resident 41's left upper quadrant (LUQ) abdomen on December 7, 2017 at 7:29 p.m., on December 8, 2017 at 10:48 p.m., and on December 9, 2017 at 10:27 p.m. 8. Novolin R was administered to Resident 41's right lower quadrant (RLQ) abdomen on December 10, 2017 at 6:47 a.m. and 9:56 p.m. 9. Novolin R was administered to Resident 41's left upper quadrant (LUQ) abdomen on December 11, 2017 at 4:22 p.m. and on December 12, 2017 at 7:19 p.m. 10. Novolin R was administered to Resident 41's right lower quadrant (RLQ) abdomen on December 21, 2017 at 6:52 p.m. and on December 22, 2017 at 6:24 pm. On December 20, 2017 at 12:11 p.m., RN 1 stated the licensed nurses should have avoided the same area where the insulin was injected previously due to possible side effects on the skin and medication side effects. RN 1 stated injecting insulin on the same site places the resident at risk for lipodystrophy (defect in the breaking down or building up of fat below the surface of the skin, resulting in lumps or small dents in the skin surface which may be caused by repeated injections of insulin in the same spot) that's why they avoid using the same site. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 20 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with Licensed Vocational Nurse 3 (LVN 3) on December 28, 2017 at 8:01 a.m., while LVN 3 was reviewing Resident 41's Location of Administration Reports for December 2017 for Lantus and Novolin R, LVN 3 was asked on the possible side effect of injecting insulin on the same site. LVN 3 answered the medication won't be absorbed and so it will be ineffective. A review of the facility's undated policies and procedures titled "Insulin Injection Administration," indicated the policy to control the blood glucose levels in patients with DM through the correct administration of insulin. The facility's policies and procedures indicated to rotate injection sites. A review of Lantus manufacturer's literature revised in March 2007 indicated as with any insulin therapy, lipodystrophy may occur at the injection site and delay insulin absorption. Other injection site reactions with insulin therapy include redness, pain, itching, hives (red and sometimes itchy bumps on the skin), swelling, and inflammation. Continuous rotation of the injection site within a given area may help to reduce or prevent these reactions. A review of Novolin R manufacturer's literature revised in February 2012, indicated Novolin R should be administered by subcutaneous injection in the abdominal region, buttocks, thigh, or the upper arm. Injection sites should be rotated within the same region to reduce the risk of lipodystrophy. b. A review of Resident 78's Admission Record indicated the resident was originally admitted to the facility on July 31, 2012 and readmitted on January 6, 2017, with a diagnosis of, but not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 21 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE limited to, type 2 diabetes mellitus (DM - high blood sugar). A review of Resident 78's Quarterly Minimum Data Set (MDS- a standardized assessment and screening tool) dated November 14, 2017, indicated the resident has severe cognitive impairment, is able to make self understood, and is able to understand others. The tool indicated the resident needs limited assistance with eating and toilet use and needs extensive assistance with bed mobility, transfers, walking in corridor, dressing, and personal hygiene. A review of Resident 78's Order Summary Report indicated a physician's order dated October 25, 2017, to administer Novolog insulin (Insulin Aspart - rapid-acting insulin [a hormone that works by lowering levels of glucose/sugar in the blood]) as per sliding scale coverage (progressive increase in the insulin dose, based on pre-defined blood glucose ranges) subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) two times a day for DM. During a record review of Resident 78's Novolog Location of Administration Report (injection site record) for December 2017, the record indicated the following findings: 1. Novolog was administered to Resident 78's right lower quadrant (RLQ) abdomen on December 4, 2017 at 6:51 a.m. and 10:37 p.m. 2. Novolog was administered to Resident 78's right lower quadrant (RLQ) abdomen on December 9, 2017 at 10:29 p.m., and on December 10, 2017 at 5:16 p.m. 3. Novolog was administered to Resident 78's left upper quadrant (LUQ) abdomen on December 11, 2017 at 4:44 p.m. and on December 12, 2017 at 11:17 p.m. 4. Novolog was administered to Resident 78's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 22 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE left upper quadrant (LUQ) abdomen on December 16, 2017 at 7:15 p.m. and on December 17, 2017 at 6:45 a.m. 5. Novolog was administered to Resident 78's left upper quadrant (LUQ) abdomen on December 18, 2017 at 6:014 p.m. and on December 19, 2017 at 5:44 a.m. 6. Novolog was administered to Resident 78's left upper quadrant (LUQ) abdomen on December 21, 2017 at 7:04 a.m. and on December 22, 2017 at 2:44 a.m. During an interview with Licensed Vocational Nurse 3 (LVN 3) on December 28, 2017 at 9:27 a.m., while LVN 3 was reviewing Resident 78's Novolog Location of Administration Report for December 2017, LVN 3 stated the licensed nurses are not rotating insulin injection sites. When asked on the relevance of rotating insulin injection sites, LVN 3 answered that if insulin is injected on the same site, there will not be enough medication absorption and the insulin will be ineffective. A review of the facility's undated policies and procedures titled "Insulin Injection Administration," indicated the policy to control the blood glucose levels in patients with DM through the correct administration of insulin. The facility's policies and procedures indicated to rotate injection sites. A review of Novolog manufacturer's literature issued in February 2015 indicated Novolog should be administered by subcutaneous injection in the abdominal region, buttocks, thigh, or the upper arm. Injection sites should be rotated within the same region to reduce the risk of lipodystrophy (defect in the breaking down or building up of fat below the surface of the skin, resulting in lumps or small dents in the skin surface). Long-term use of insulin, including Novolog, can cause lipodystrophy at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 23 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the site of repeated insulin injections. Lipodystrophy includes lipohypertrophy (thickening of fat under the skin) and lipoatrophy (wasting of fat under the skin), and may affect insulin absorption. c. A review of Resident 102's Admission Record indicated the resident was originally admitted to the facility on July 14, 2015 and readmitted on August 27, 2017, with a diagnosis of, but not limited to, type 2 diabetes mellitus (DM - high blood sugar). A review of Resident 102's Quarterly Minimum Data Set (MDS- a standardized assessment and screening tool) dated December 8, 2017, indicated the resident has severe cognitive impairment, usually is able to make self understood, and usually is able to understand others. The tool indicated the resident is totally dependent with bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 102's Order Summary Report indicated a physician's order dated August 27, 2017, to administer Levemir Solution (Insulin Detemir - long-acting - up to 24 hours duration of action insulin [a hormone that works by lowering levels of glucose/sugar in the blood]) inject five (5) units subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) every 12 hours for DM. During a record review of Resident 102's Levemir Location of Administration Report (injection site record) for December 2017, the record indicated the following findings: 1. Levemir was administered to Resident 102's left upper quadrant (LUQ) abdomen on December 3, 2017 at 10:33 p.m. and December 4, 2017 at 9:32 a.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 24 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. Levemir was administered to Resident 102's left upper quadrant (LUQ) abdomen on December 5, 2017 at 9:39 a.m. and 8:37 p.m. and on December 6, 2017 at 9:35 a.m. 3. Levemir was administered to Resident 102's right lower quadrant (RLQ) abdomen on December 7, 2017 at 8:34 a.m. and 5:33 p.m. and on December 8, 2017 at 9:24 a.m. 4. Levemir was administered to Resident 102's left upper quadrant (LUQ) abdomen on December 9, 2017 at 11:29 a.m. and 10:27 p.m. 5. Levemir was administered to Resident 102's right lower quadrant (RLQ) abdomen on December 11, 2017 at 9:13 a.m. and 9:57 p.m. 6. Levemir was administered to Resident 102's left upper quadrant (LUQ) abdomen on December 12, 2017 at 8:54 a.m. and 7:25 p.m. and on December 13, 2017 at 8:44 a.m. 7. Levemir was administered to Resident 102's left upper quadrant (LUQ) abdomen on December 14, 2017 at 8:24 a.m. and on December 15, 2017 at 9:33 a.m. 8. Levemir was administered to Resident 102's left arm on December 20, 2017 at 9:14 p.m. and on December 21, 2017 at 8:12 a.m. During an interview with Licensed Vocational Nurse 3 (LVN 3) on December 28, 2017 at 12:28 p.m., while LVN 3 was reviewing Resident 102's Levemir Location of Administration Report for December 2017, LVN 3 stated the insulin injections sites were not rotated. When asked on the relevance of rotating insulin injection sites, LVN 3 answered the medication will be ineffective due to poor absorption if insulin is continued to be injected on the same site. A review of the facility's undated policies and procedures titled "Insulin Injection Administration," indicated the policy to control the blood glucose levels in patients with DM FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 25 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE through the correct administration of insulin. The facility's policies and procedures indicated to rotate injection sites. A review of Levemir manufacturer's literature issued on June 16, 2005 indicated as with any insulin therapy, lipodystrophy (defect in the breaking down or building up of fat below the surface of the skin, resulting in lumps or small dents in the skin surface which may be caused by repeated injections of insulin in the same spot) may occur at the injection site and delay insulin absorption. Other injection site reactions with insulin therapy may include redness, pain, itching, hives (red and sometimes itchy bumps on the skin), swelling, and inflammation. Continuous rotation of the injection site within a given area may help to reduce or prevent these reactions. d. A review of Resident 6's Admission Record indicated the resident was originally admitted to the facility on July 22, 2008 and readmitted on September 14, 2017, with a diagnosis of, but not limited to, type 2 diabetes mellitus (DM high blood sugar). A review of Resident 6's Quarterly Minimum Data Set (MDS- a standardized assessment and screening tool) dated September 21, 2017, indicated the resident has severe cognitive skills for daily decision-making, rarely/never makes self understood, and rarely/never able to understand others. The tool indicated the resident is totally dependent with transfers, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 6's Order Summary Report indicated a physician's order dated October 25, 2017, to administer Insulin Aspart (rapid-acting insulin [a hormone that works by lowering levels of glucose/sugar in the blood]) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 26 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE inject as per sliding scale coverage (progressive increase in the insulin dose, based on pre-defined blood glucose ranges) subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) before meals and at bedtime for DM. During a record review of Resident 6's Insulin Aspart Location of Administration Report (injection site record) for December 2017, the record indicated the following findings: 1. Insulin Aspart was administered to Resident 6's right lower quadrant (RLQ) abdomen on December 3, 2017 at 10:31 p.m. and on December 4, 2017 at 7:19 p.m. and 10:36 p.m. 2. Insulin Aspart was administered to Resident 6's left upper quadrant (LUQ) abdomen on December 5, 2017 at 8:20 p.m. and 6:38 p.m. 3. Insulin Aspart was administered to Resident 6's right lower quadrant (RLQ) abdomen on December 9, 2017 at 7:27 p.m. and 10:25 p.m. 4. Insulin Aspart was administered to Resident 6's left upper quadrant (LUQ) abdomen on December 10, 2017 at 9:55 p.m. and on December 11, 2017 at 7:01 a.m. 5. Insulin Aspart was administered to Resident 6's left upper quadrant (LUQ) abdomen on December 12, 2017 at 10:24 p.m. and on December 13, 2017 at 12:03 p.m. 6. Insulin Aspart was administered to Resident 6's right lower quadrant (RLQ) abdomen on December 13, 2017 at 5:14 p.m. and on December 14, 2017 at 11:52 a.m. 7. Insulin Aspart was administered to Resident 6's left upper quadrant (LUQ) abdomen on December 15, 2017 at 7:23 p.m. and 9:25 p.m. 8. Insulin Aspart was administered to Resident 6's left upper quadrant (LUQ) abdomen on December 18, 2017 at 5:49 p.m. and 8:48 p.m. and on December 19, 2017 at 5:45 a.m. and 11:39 a.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 27 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's undated policies and procedures titled "Insulin Injection Administration," indicated the policy to control the blood glucose levels in patients with DM through the correct administration of insulin. The facility's policies and procedures indicated to rotate injection sites. A review of Insulin Aspart manufacturer's literature indicated the medication should be administered by subcutaneous injection in the abdominal wall, the thigh, or the upper arm. Injection sites should be rotated within the same region. e. A review of the admission record indicated Resident 88 was admitted on October 3, 2017, with diagnoses including muscle weakness and hypertension (high blood pressure). A review of Resident 88's history and physical examination dated October 5, 2017 indicated Resident 88 had the capacity to understand and make decisions. A review of Resident 88's care plan dated January 4, 2017 indicated the resident is at risk for fluctuation in blood pressure level related to hypertension. The interventions in the care plan included giving blood pressure medications as ordered. A review of Resident 88's physician orders dated October 3, 2017 indicated Metoprolol 50 milligram (mg) was to be given by mouth, twice a day and to hold the medicine for systolic blood pressure (SBP- the blood pressure when the heart is contracting) less than 120 millimeters of mercury (mmHg -the units used to measure blood pressure). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 28 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 88's Medication Administration Record (MAR) indicated metoprolol was given to the resident when the medication was supposed to held per the physician ordered SBP parameter on the following dates: 1. On October 6, 2017 at 5:30 p.m., SBP was 113 mmHg 2. On October 9, 2017 at 5:30 p.m., SBP of 115 mmHg. 3. On October 16, 2017 at 5:30 p.m., SBP of 113 mmHg. 4. On October 20, 2017 at 5:30 p.m., SBP of 112 mmHg. 5. On November 1, 2017 at 5:30 p.m., SBP of 114 mmHg. 6. On November 5, 2017 at 5:30 p.m., SBP of 115 mmHg. 7. On November 14, 2017 at 5:30 p.m., SBP of 116 mmHg. 8. On November 16, 2017 at 5:30 p.m., SBP of 115 mmHg. 9. On November 28, 2017 at 5:30 p.m. SBP of 117 mmHg. 10. On December 14, 2017 at 5:30 p.m., SBP of 118 mmHg. 11. On December 15, 2017 at 5:30 p.m., SBP of 114 mmHg. 12. On December 20, 2017 at 5:30 p.m., SBP of 114 mmHg. On December 21, 2017 at 3:52 p.m., during an interview, Registered Nurse 2 (RN 2) stated the licensed nurse should not have given the medication to Resident 88 when the systolic blood pressure was less than 120 mmHg. RN 2 stated she would do a one to one in-service with the licensed nurses. A review of the facility's undated policy and procedure titled "Administering Medications" indicated medications shall be administered in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 29 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a safe and timely manner and as prescribed. The policy and procedure also indicated medications must be administered in accordance with the orders including required period. f. A review of the admission record indicated Resident 35 was originally admitted to the facility on June 2, 2017, and readmitted on September 19, 2017, with diagnoses that included muscle weakness and chronic obstructive pulmonary disease (COPD- a lung disease characterized by long-term poor airflow). A review of a Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated September 26, 2017, indicated Resident 35 had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required extensive assistance for transfer, bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 35's physician order dated September 19, 2017, indicated to administer Doxazosin Mesylate tablet 4 milligram (mg) by mouth two times a day for hypertension and to hold medication for systolic blood pressure (SBP) below 125 millimeters of mercury (mmHg -the units used to measure blood pressure. Below 120 systolic and below 80 diastolic is considered a normal adult blood pressure). A review of Resident 35's Medication Administration Record (MAR) indicated Doxazosin Mesylate tablet was administered to the resident when it was supposed to held per the SBP parameter on the following dates: 1. On September 22, 2017 at 9 a.m., SBP was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 30 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 124 mmHg. 2. On September 25, 2017 at 9 p.m., SBP was 116 mmHg. 3. On October 4, 2017 at 9 p.m., SBP was 121 mmHg. 4. On October 7, 2017 at 9 p.m., SBP of 119 mmHg. 5. On October 10, 2017 at 9 p.m., SBP of 114 mmHg. 6. On October 15, 2017 at 9 p.m., SBP of 119 mmHg. 7. On October 16, 2017 at 9 p.m., SBP of 118 mmHg. 8. On October 17, 2017 at 9 p.m., SBP of 118 mmHg. 9. On November 2, 2017 at 9 p.m., SBP of 118 mmHg. 10. On November 9, 2017 at 9 p.m., SBP of 120 mmHg. 11. On November 22, 2017 at 9 p.m., SBP of 114 mmHg. 12. On December 1, 2017 at 9 p.m., SBP of 120 mmHg. 13. On December 4, 2017 at 5:30 p.m., SBP of 120 mmHg. On December 21, 2017 at 10:07 a.m., during an interview and record review of the MAR for the month of November 2017, RN 2 verified the MAR indicated SBP less than 125 but the medication was given. RN 2 stated the medication should not have been given. RN 2 stated the facility does an in-service every morning. The RN supervisor stated they would do a one to one in-service. A review of the facility's undated policy and procedure titled "Administering Medications" indicated medications shall be administered in a safe and timely manner and as prescribed. The policy and procedure also indicated medications must be administered in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 31 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE accordance with the orders including required period.

F679 SS=D Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1)

F679 01/17/2018 §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one out of 35 sampled residents (Resident 107) identified with low function was provided with activities that stimulates the resident's senses. This deficient practice had the potential not to meet the highest practicable psychosocial wellbeing of the resident. Findings: A review of Resident 107's admission record indicated an initial admission to the facility on June 14, 2016 and the most recent readmission dated October 31, 2017, with diagnoses including dysphasia (language disorder marked by deficiency in the generation of speech, and sometimes also in its comprehension, due to brain disease or damage), abnormal posture, and osteoporosis FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 32 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (a bone disease that occurs when the body loses too much bone makes too little bone, or both). A review of Resident 107's Minimum Data Set (MDS - a standardized comprehensive assessment and care planning tool) dated September 12, 2017, indicated the resident was rarely/never able to understand others and rarely/never made herself understood. The resident required total assistance with one person physical assistance with bed mobility, toilet use, and personal hygiene. A review of Resident 107's History and Physical report dated October 31, 2017, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 107's care plan dated November 13, 2017, indicated the resident was low functioning with need for supportive activities. The goal indicated the resident will maintain eye contact with activity staff at least 10 to 15 minutes three times a week. The care plan interventions indicated to provide eye to eye contact at least three times a week and stimulate senses through touch, stroking, or squeezing residents' hands. A review of Resident 107's activity attendance record for the month of November 2017, indicated the activity staff provided one to one room visit eight times, instead of 12 times (three times a week for four weeks) as indicated in the care plan. The activity staff provided conversation/social contact and the resident responded verbally. The resident's independent activity included watching television/movie and socializing. A review of quarterly activity assessment dated December 13, 2017, indicated that Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 33 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 107 was non-verbal and unable to make her needs known. The activity assessment indicated Resident 107 was very low functioning with need for supportive activities. The activity staff provided one to one room visits three times a week and the resident enjoyed listening to music. The goal was for Resident 107 to maintain eye contact with activity staff at least 10 to 15 minutes three times a week. A review of Resident 107's activity attendance record for the month of November 2017, indicated that by December 21, 2017, the activity staff provided one to one room visit six times, instead of nine times (three times a week for three weeks) as indicated in the care plan. The activity staff provided conversation/social contact and the resident responded verbally. The resident's independent activity included watching television/movie and socializing. On December 21, 2017 at 10:08 a.m., during an observation, Resident 107 was in lying in bed. Certified Nursing Assistant 1 (CNA 1), who was present during the observation stated that the resident was non- verbal. On December 28, 2017 at 10:06 a.m., during an interview, the Activity Director (AD) stated that Resident 107 was to receive activities at least 3 times a week. After reviewing Resident 107's activity attendance record, the AD stated that Resident 107 was not provided activity (one to one room visit) three times a week. The AD stated Resident 107's activity attendance record indicated that the responded verbally, watched Television, and socialized with visitors. The AD also stated that eye to eye contact was a form of conversation. On December 28, 2017 at 10:16 a.m., during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 34 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE an interview, Licensed Vocational Nurse 1 (LVN 1) stated that Resident 107 was nonverbal. LVN 1 stated that she reviewed Resident 107's activity attendance record for the month of November 2017, and could provide documented evidence the activity staff stimulated Resident 107's senses through touch, stroking, or squeezing resident's hands as indicated in the care plan. A review of the facility's undated policy and procedure titled "Activity Programs" indicated that the facility's activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 01/19/2018 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure two of 35 sampled residents Resident 107 and Resident 4 were provided necessary treatment and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 35 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE services to prevent formation of and promote healing of pressure sore by: 1. Failure to promptly act upon the interdisciplinary team (IDT -a coordinated group of staff from different fields who work together toward a common goal) recommendations for Resident 107 to have wound care consultation (10 day delay), Registered Dietitian (RD) consultation (12 day delay), and increased frequency of Pro-stat (a liquid protein to promote wound healing - five day delay). 2. Failure to continuously monitor Resident 107's wound to include October 5, 2017 during 3 p.m. to 11 p.m. shift, October 6, 2017 during 7 a.m. to 3 p.m. shift, and October 7, 2017 during 11 p.m. to 7 a.m. shift, when the resident's skin condition changed to ensure timely medical intervention. 3. Failure to provide Resident 107 with a low air loss mattress (a pressure relieving mattress for the management of pressure sores) to prevent the progression of a stage 2 pressure ulcer identified on October 5, 2017, until the pressure ulcer worsened to a stage 4, on October 16, 2017. 4. Failure to ensure a resident was provided with heel protector (pressure relieving devices) to left and right heels as directed by the physician (Resident 4). 5. Failure to ensure a resident was provided with functional Alternating Pressure Pad (APP mattress - systems used to prevent stage 1 bedsores) as directed by the physician for Resident 4. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 36 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE As a result, Resident 107's healed pressure sore on the coccyx reopened, and between October 5, 2017 and October 16, 2017, the resident's pressure sore worsened to a stage 4 pressure sore (full thickness tissue loss with exposed bone, tendon, or muscle), and Resident 4 was placed at additional risk for developing pressure sores. Findings: a. A review of the Admission Record indicated Resident 107 was initially admitted to the facility on June 14, 2016, with the most recent readmission on October 31, 2017, with diagnoses including abnormal posture, osteoporosis (a bone disease that occurs when the body loses too much bone makes too little bone, or both), and pressure sore (injury to skin and underlying tissue resulting from prolonged pressure on the skin). The body assessment dated September 6, 2017, indicated Resident 107 did not have any skin breakdown and was noted with an old scar on the coccyx (a bone at the base of the spinal column) area. A review of the Nutritional Screening Data of September 11, 2017, indicated Resident 107 had a 14.9 % weight loss in the last 180 days. Laboratory test results dated September 5, 2017, indicated hemoglobin (red protein responsible for transporting oxygen in the blood) was 33.2 percent (%) with a reference range of 34.1- 44.9 %, the hematocrit (the ratio of the volume of red blood cells to the total volume of blood) 10.3 grams per deciliter (g/dl) with a reference range of 11.2 g/dl to 15.7 g/dl. There was no albumin or pre albumin laboratory test result indicated on the Screening Data. (Serum proteins such as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 37 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE albumin and pre albumin (PAB) have are used to determine patient nutritional status). The Minimum Data Set (MDS - a standardized comprehensive assessment and care planning tool) dated September 12, 2017, indicated Resident 107 was rarely/never able to understand or be understood, required total assistance with one-person physical assistance with bed mobility, toilet use, and personal hygiene, eating, and was at risk of developing pressure sore. A review of the Care Plan developed on September 15, 2017, for Resident 107's potential for pressure sore development related to impaired bed mobility and incontinence of bowel and bladder functions, had a goal for Resident 107 to have intact skin, free of redness, blisters or discoloration through review date. The interventions included administering treatment as ordered and monitoring effectiveness; educating the resident/family/caregivers as to causes of skin breakdown, and follow the facility's policies/protocols for the prevention/treatment of skin breakdown. The wound evaluation flow sheet indicated the resident was treated with Calmoseptine with A and D (skin protectant) beginning on September 25, 2017. A review of the Braden Scale (a tool to assess a resident's risk for pressure sore) dated September 20, 2017, indicated Resident 107 had a total score of 14 (moderate risk for pressure sore development). A review of the Care Plan developed on September 25, 2017, for Resident 107's altered skin integrity at the coccyx area, had a goal for the pressure sore to improve in size and stage without any complications. The interventions included baseline laboratory work -any test FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 38 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE than measures current or pre-treatment parameters, against which response(s) to therapy, if any, is evaluated, (as available), monitoring the pressure sore weekly, RD consult, and wound consult and weekly followup. A review of Resident 107's Skin Integrity Review dated October 6, 2017, indicated the IDT recommended for the stage 2 pressure ulcer on the coccyx, for the resident to have a wound consult, and Registered Dietitian consult and Pro-stat increase. A review of Resident 107's Wound Evaluation Flowsheet indicated: -On September 25, 2017 the pressure sore Stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence) measuring 1.5 centimeter (cm) length by 1.7 cm width. - On October 5, 2017, the pressure sore was a Stage 2 (partial thickness loss of skin presenting as a shallow open sore with red pink wound bed) measuring 2.5 cm length by 2.0 cm width by 0.1 cm depth with scant (very little) drainage. - On October 12, 2017, the pressure sore worsened to an unstageable (full thickness tissue loss in which the base of the sore is covered by slough (dead tissue), measuring 2.5 cm length by 2.0 cm width by 0.1 cm depth, with scant drainage and 80 percent (%) slough. - On October 16, 2017, the sore was a Stage 4 measuring 4.5 cm length by 5.1 cm width by 2.5 cm depth, with scant drainage, 50 % slough, and 50% eschar (dead tissue). The flowsheet indicated a low air loss mattress was added as a current preventative intervention. A review of Resident 107's laboratory result dated October 17, 2017, indicated the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 39 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE had an albumin level of 2.1 gram per deciliter (low in a reference range of 3.5-5.7 g/dl) and pre-albumin level of 8 mg/dl (low in a reference range of 17-34 mg/dl). On December 21, 2017 at 10:13 a.m., during an observation in the presence of Certified Nursing Assistant 1 (CNA 1), Resident 107 was lying in bed. During a concurrent interview, CNA 1 stated the resident had a pressure sore. On December 22, 2017 at 9:20 a.m., during a wound care treatment observation, Resident 107 was lying in bed, on a low air loss (LAL) mattress, Licensed Vocational Nurse 2 (LVN 2) removed the soiled dressing, irrigated (washed) the wound with normal saline (salt water) and described the wound as Stage 4 pressure sore with 95% pink wound bed and slight whitish tissue. On December 22, 2017 at 2:14 p.m., during an interview, LVN 1 stated Resident 107 developed an unstageable pressure sore on October 12, 2017. LVN 1 stated if ordered, the LAL mattress is received within 24 hours. LVN 1 stated she could not explain why the LAL mattress was not ordered before the pressure sore deteriorated. (The wound evaluation flowsheet indicated a low air loss mattress was added as a current preventative intervention on October 16, 2017. On December 27, 2017 at 9 a.m., during an interview while reviewing the nursing notes, LVN 1 stated the licensed nursing staff did not monitor Resident 107's unstageable pressure sore from October 12, 2017 to October 16, 2017, as indicated in the facility's change of condition policy. On December 27, 2017 at 3:15 p.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 40 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE interview, LVN 1 stated she reviewed Resident 107's nutritional notes and stated the RD did not evaluate the resident until October 18, 2017, 12 days after the IDT recommendation. LVN 1 stated the wound consultant did not evaluate Resident 107's pressure sore until October 16, 2017, 10 days after the IDT recommendation. LVN 1 reviewed Resident 107's physician orders and stated that the Prostat frequency was not increased to twice a day until October 11, 2017, five days after the IDT recommendation. On December 27, 2017 at 4:01 p.m. during an interview, the Director of Nursing (DON) stated the IDT recommendation should have been acted upon as soon as possible. LVN 1, who was present during the interview, stated the development of the Stage 2 pressure sore dated October 5, 2017, was a change of condition (COC). LVN 1 stated after Resident 107's COC, the nursing staff was to monitor the resident's skin every shift for 72 hours. LVN 1 stated the licensed nursing staff did not monitor Resident 107's skin status on October 5, 2017 during 3 p.m. to 11 p.m. shift, October 6, 2017 during 7 a.m. to 3 p.m. shift, and October 7, 2017 during 11 p.m. to 7 a.m. shift. A review of Resident 107's IDT Conference Record dated October 19, 2017, indicated the resident developed the pressure ulcer on the coccyx area where the old scar is. (Scar tissue is not as strong as healthy tissue and is more likely to break down again). A review of the facility's undated policy titled "Comprehensive Person-Centered Care Planning Process" indicated that the purpose of the policy was to develop and implement a baseline and comprehensive person-centered care planning for each resident which meets the standards of quality of care in a timely FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 41 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE manner and provided by qualified professionals who are culturally competent. A review of the facility's undated policy titled "Change of Condition" indicated that when a resident's condition changed for any reason, the facility will initiate "Change of Condition" assessment which is based on SBAR communication tool and insure proper care and follow-up by using a monitoring system using a 72 hours charting. The charting will be completed during each shift for 72 hours from the time of condition noted. When a resident's condition changes, the physician will be called promptly. A review of the facility's undated policy and procedure titled "Pressure Sore Risk Assessment Tool" indicated the licensed nurse is responsible to initiate the use of appropriate prevention protocols: prevent pressure, skin care, prevent shearing/friction, nutrition, control of incontinence, pressure relief. A review of the facility's undated policy and procedure titled, "Wound Management and Skin Integrity," indicated wound management minutes should include: meeting dates, members present, resident reviewed and any necessary follow-up. The procedure includes frequency of assessment (changes in condition with a potential to trigger a care plan for pressure sores) and discussion terms (interdisciplinary goals, resident's progress, resident's identifies with condition, equipment needs/revision, and care planning). b. A review of the admission record indicated Resident 4 was originally admitted to the facility on January 1, 2009 and readmitted on September 13, 2016 with diagnoses that included convulsions, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and dementia FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 42 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (loss of memory and other mental abilities severe enough to interfere with daily life). The Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool), dated September 18, 2017, indicated Resident 4's cognition was severely impaired in daily decision-making. According to the MDS, the resident was assessed as needing full staff assistance with eating, toilet use, personal hygiene, and bathing, transferring, and requiring extensive assistance with bed mobility and dressing. According to the MDS, the resident was identified as at risk for developing pressure ulcer. The Braden Scale - For Predicting Pressure Sore Risk dated, September 18, 2017 indicated Resident 4 had a score of 13 that corresponded to as moderate risk. A record review of the physician's order dated September 14, 2016, indicated to apply heel protector for skin management and monitor every shift for Resident 4. On May 11, 2017 at 8:37 a.m., Resident 4 was observed lying in his bed without wearing heel floater on the right heel in the presence of a Licensed Vocational Nurse (LVN 3). On concurrent interview at 8:37 a.m., LVN 3 stated there was only one heel floater on because the resident did not like having the boot or floater on his left foot. Resident 12 was observed talking to self, confused, and listening to the radio unable to explain why he did not want to have the heel protector on. On December 20, 2017 at 9:24 a.m., during an observation, Resident 4 did not have heel protectors on. During a concurrent interview, Registered Nurse 2 (RN 2) stated the heel protectors were in the closet. RN 2 also stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 43 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the heal protectors were usually placed on the resident after morning care. RN 2 stated the Restorative Nursing Assistant (RNA) usually applies the heel protector. A record review of Resident 4's care plan titled "The resident has potential for pressure ulcer development related to history of ulcers, immobility, seizure disorder," initiated on September 14, 2016, indicated heal protector for skin maintenance and to administer treatment as ordered and monitor for effectiveness an intervention. A review of the physician order dated July 13, 2017 indicated to provide APP mattress to prevent pressure and monitor pump and mattress for leaking every shift for Resident 4. On December 20, 2017 at 9:22 a.m., during an observation and interview, RN 2 verified Resident 4's APP matters pump was not functioning. RN 2 stated the APP mattress was on but the pump was not working thus the maintenance is replacing it now. A review of the facility's undated policy and procedure and titled "Pressure Ulcer Treatment," indicated to implement pressurerelieving device(s) in accordance with resident's assessed needs.

F688 SS=G Increase/Prevent Decrease in ROM/Mobility CFR(s): 483.25(c)(1)-(3)

F688 02/22/2018 §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 44 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure four of 35 sampled residents (Residents 107, 93, 75 and 4) with or without limited range of motion (ROM the extent of movement of a joint), and limited mobility, received appropriate treatment and services to increase ROM, prevent further decrease in ROM, and maintain or improve mobility, including: 1. Failure to identify Resident 107's decline in ROM. 2. Failure to notify the rehabilitation department of Resident 107's limitation in joint mobility. 3. Failure to monitor Resident 107's pain and stiffness as indicated in the care plan. 4. Failure to ensure Residents 107, 93, and 75 were provided with complete ROM exercises to all joints as indicated in the facility's policy and procedure for Range of Motion Exercises. 5. Failure to accurately assess Resident 75's ROM of his left hand fingers. 6. Failure to apply hand roll as ordered by the physician and document the RNA treatment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 45 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE provided to the resident (Resident 4). As a result, by December 21, 2017, Resident 107 had limited (decline) ROM to her lower extremities joints, left elbow, right wrist, and right hand fingers. This also resulted in placing Residents 93, 75 and 4, at increased risk for ROM decline. Findings: a. A review of Resident 107's admission record indicated an initial admission to the facility on June 14, 2016 and the most recent readmission was on October 31, 2017, with diagnoses including abnormal posture, osteoporosis (a bone disease that occurs when the body loses too much bone, makes too little bone, or both), and high blood pressure. A review of Resident 107's quarterly Minimum Data Set (MDS a standardized comprehensive assessment and care planning tool) dated December 21, 2016, indicated the resident was rarely/never able to understand others and rarely/never made herself understood. The resident required total assistance with one person physical assistance with dressing and personal hygiene. The MDS also indicated the resident had no impairment with functional limitation in ROM to both sides of her upper (shoulder, elbow, wrist, and hand) and lower (hip, knee, ankle, and foot) extremities. A review of Resident 107's quarterly MDS dated March 31, 2017, indicated Resident 107 had functional limitation in ROM to both sides of her upper and no impairment to both sides of her lower extremities. A review of Resident 107's significant change MDS dated September 12, 2017, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 46 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 107 had functional limitation in ROM to both sides of her upper and lower extremities. A review of the Joint Mobility Assessment (JMA) dated November 1, 2017, indicated Resident 107 had ROM within functional limitation (variance due to normal aging process allowed) to her left and right hip, knee, and ankle, left elbow, right wrist, and right hand fingers joints. The physician's orders dated November 1, 2017, indicated the followings: 1. Restorative Nursing Assistant (RNA) to perform passive range of motion (PROM no participation of the resident) exercise to both (right and left) upper extremities and lower extremities seven times a week or as tolerated. 2. RNA to apply right elbow splint for 4 to 6 hours or as tolerated with skin check, seven times a week, one time a day. A review of Resident 107's care plan dated November 1, 2017, indicated the resident was at risk for decline in ROM. The care plan goal indicated Resident 107 will maintain current ROM. The interventions indicated for the RNA to perform gentle PROM exercise to both (right and left) upper and lower extremities and apply right elbow splint for 4 to 6 hours or as tolerated with skin check. A review of Resident 107's care plan dated November 15, 2017, indicated the resident had potential for further contracture related to impaired mobility. The resident will have no further contracture in the next three months. The care plan interventions indicated to keep contracted areas clean and odor free, monitor for pain or increased stiffness, and perform FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 47 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ROM as ordered. A review of Resident 107's RNA weekly progress notes dated November 15, 2017, indicated the resident's overall participation was uncooperative and her overall tolerance to the ROM exercises was fair. A review of the Quarterly JMA dated December 13, 2017, indicated Resident 107 had no change in condition noted. The JMA also indicated the ROM exercise maintained Resident 107's assessed mobility. The plan was to continue with the RNA program. A review of Resident 107's RNA weekly progress notes dated December 14, 2017, indicated the resident's overall participation was combative and her tolerance fair. On December 21, 2017 at 02:01 p.m., during an observation in the presence of RNA 1 (assisting), RNA 2 was observed performing PROM exercise for Resident 107. The resident was grimacing and moaning at times during ROM exercises. RNA 2 was observed to not fully perform PROM as follows: Right and left extremities range of motion RNA 2 did not attempt and/or perform flexion and extension (bending and straightening) of the left shoulder, left and right wrist, left and right hip, and left and right toes; abduction and adduction (moving away and into starting position)of the right and left shoulder, and left and right hip; ulnar and radial deviation (moving wrist side to side) of the left and right wrist; plantar flexion and dorsiflexion (moving foot up and down) of the left and right ankles. During observation, Resident 107 had limited ROM to the right shoulder, left hand fingers, right and left elbows, knees, and elbows. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 48 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On December 21, 2017, during an interview after performing the PROM exercises to Resident 107, RNA 2 stated she only performed PROM to the knees and right elbow because the resident was contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). RNA 2 stated she did not perform PROM to the feet, hips, and left shoulder because RNA focused on the contracted knees and right elbow. RNA 2 stated she did not perform PROM to left shoulder because by performing PROM to left elbow, she was also exercising the left shoulder. On December 22, 2017 at 9:53 a.m., during an interview in the presence of Occupational Therapist 1 (OT 1), and Physical Therapist (PT 1), stated he did not see any problems with the RNAs performing ROM exercises, when conducting random competency skills evaluation of the RNAs. PT 1 and OT 1 stated they instructed the RNAs to provide ROM exercises as follow: flexion/extension of the hip, knee, wrist, ankle, shoulder, elbow, hand digits, and metacarpal (MCP bones of the hand) joints, abduction/adduction of the shoulder and hip joints. PT 1 and OT 1 stated the rehabilitation department did not have a resource material and/or manual on how to perform ROM exercises. PT 1 and OT 1 stated the expectation was for the RNAs to provide ROM exercises to all the resident' joints as instructed. Per OT 1, RNA 2 should have performed ROM to each joint because Resident 107 had limited ROM of her upper extremities. On December 22, 2017 at 10:11 a.m., during observation, Physical Therapist 1 (PT 1) assessed the ROM of Resident 107's right and left lower extremities. Resident 107, had limited FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 49 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ROM to her knees (unable to extend the knees). Per PT 1, resident was "tight". During a concurrent interview, PT 1 stated he was unable to assess Resident 107's hip joints to be within functional limit because her knees needed to be straight (extended). PT 1 stated he did not want to force it (continue assessing Resident 107's hip). Resident 107 was grimacing and moaning at times during the assessment; she would bring her knees toward her body when PT 1 attempted to straighten them. On December 22, 2017, during an observation following PT 1's assessment, Occupational Therapist 1 (OT 1) assessed the ROM of Resident 107's upper extremities. Per OT 1, Resident 107 was tight, which resulted in Resident 107 having limited ROM to the following joints: right shoulder flexion: moderate to severe, right shoulder abduction moderate to severe, right elbow extension (severe), right wrist (moderate to severe), right fingers metacarpal (minimal to moderate), left shoulder (moderate limitation for extension and abduction), left elbow flexion (minimal to moderate OT 1 stated resident was resisting). On December 22, 2017 at 01:53 p.m., during a follow up interview, RNA 2, stated she had been working with Resident 107 about once a week. RNA 2 stated Resident 107 had limited ROM to her knees (unable to straighten knee). RNA 2 stated the RNAs and therapists (PT/OT) knew about the limitation. RNA 2 stated Resident 107 was unable to have her knees' ROM within functional limit even when she was not in pain and/or stiff. RNA 2 stated she did not personally report Resident 107's limitation. On December 22, 2017 02:50 p.m., during an interview, RNA 1 stated Resident 107's ROM of her knees had been limited since working with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 50 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the resident (six to seven months ago). RNA 1 stated she was unable to perform full ROM to Resident 107's knees (unable to extend the knees). RNA 1 also stated Resident 107's knees could not be fully extended even when the resident was relaxed and not tense/stiff. On December 22, 2017 at 05:50 p.m., during an observation, the Director of Nursing (DON) attempted to assess Resident 107's ROM. The DON was unable to assess the ROM of the resident's lower extremities (unable to extend the legs). Resident 107 was moaning and grimacing. During a concurrent interview, the DON stated Resident 107 was "tense" at the time and she would stop the ROM assessment to request for pain medication. On December 27, 2017 at 08:10 a.m., during a phone interview, Resident 107's family member (FM 1) stated Resident 107's legs "were stretched out more" when she was initially admitted to the facility in June 2016. FM 1 stated Resident 107 had been more in a fetal position (in this position, the back is curved, the head is bowed, and the limbs are bent and drawn up to the torso) since insertion of the gastrostomy tube [GT a tube inserted into the stomach through a surgical incision use for feeding and administration of medication for a resident unable to swallow]. FM 1 stated she did not remember when the GT was inserted, maybe a couple of months ago. On December 27, 2017 at 9:19 a.m., during an observation, RNA 3 was observed performing PROM exercise to Resident 107. Resident 107 was opening her eyes and mouth wide and pulling back her extremities during ROM exercises. RNA 3 was observed to not fully perform PROM as follows: Right and left extremities range of motion RNA FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 51 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3 did not attempt and/or perform flexion and extension (bending and straightening) of the right and left shoulders, left and right wrists, left and right hips, and left and right toes; abduction and adduction (moving away and into starting position) of the left and right hip; ulnar and radial deviation (moving wrist side to side) of the left and right wrist; plantar flexion and dorsiflexion (moving foot up and down) of the left and right ankles. During observation, Resident 107 had limited ROM to her knees. On December 27, 2017, during an interview after performing the PROM exercises to Resident 107, RNA 3 stated Resident 107 was sometimes hard to move her joints during exercise. RNA 3 stated she would notify the charge nurse or therapists. RNA 3 also stated she did not perform flexion/extension of the wrist and shoulders and abduction/ adduction of the hips. On December 27, 2017 at 10:15 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she reviewed Resident 107's nursing notes and the RNA weekly notes dated November 15, 2017 and December 14, 2017, but could not find documented evidence the RNA reported to the licensed nursing staff and/or the rehabilitation department the resident was uncooperative or combative during ROM exercises. LVN 1 could not provide documented evidence the physician was notified of Resident 107's limited ROM. LVN 1 stated if the resident was uncooperative or combative, the RNA should have stopped the treatment (ROM exercise) and notified the licensed nurse. On December 28, 2017 at 12:31 p.m., during a follow up interview, LVN 1 stated she reviewed Resident 107's care plan for contracture prevention dated November 15, 2017, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 52 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE could not find documented evidence the licensed nursing staff and the RNAs were monitoring for pain and/or stiffness as indicated in the care plan intervention. On December 28, 2017 at 3:20 p.m., during an interview, PT 1 and OT 1 stated it was the facility's procedure for the RNAs to notify the charge nurse if there was a change of condition (limited ROM, contracture development). The charge nurse would then notify the rehabilitation department of the change. PT 1 stated it was the expectation of the RNA to notify the charge nurse if a resident experienced pain or stiffness, and/or exhibited resistive behavior during ROM exercises. PT 1 and OT 1 stated the rehabilitation department was not notified of Resident 107's tightness, stiffness, or resistance during ROM exercises. A review of the Facility's undated policy and procedure titled "Range of Motion Exercises" indicated the purpose of the procedure was to exercise the resident's joints and muscles. Review the resident's care plan to assess for any special needs of the resident. Exercise the shoulder, elbow, wrist, thumb, fingers, hip, knee, feet, and toes. Document the date and time the exercise was performed, if and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure, any problems or complaints made by the resident related to the procedure. Notify the charge nurse or supervisor if the resident refuses the exercises. Report other information in accordance with the facility policy and professional standards of practice. A review of the facility's undated policy titled "Comprehensive Person Centered Care Planning Process" indicated the purpose of the policy was to develop and implement a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 53 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE baseline and comprehensive person centered care planning for each resident which meets the standards of quality of care in a timely manner and provided by qualified professionals who are culturally competent. A review of the facility's undated policy titled "Change of Condition" indicated when a resident's condition changed for any reason, the facility will initiate "Change of Condition" assessment which is based on SBAR communication tool and insure proper care and follow up by using a monitoring system using a 72 hours charting. The charting will be completed during each shift for 72 hours from the time of condition noted. When a resident's condition changes, the physician will be called promptly. b. A review of Resident 93's admission record indicated an initial admission to the facility on January 1, 2009 and the most recent readmission was on May 31, 2016, with diagnoses including osteoporosis (a bone disease that occurs when the body loses too much bone makes too little bone, or both), and high blood pressure. The physician's orders dated February 23, 2017, indicated Restorative Nursing Assistant (RNA) to perform gentle passive range of motion (PROM no participation of the resident) exercise to both (right and left) upper extremities and lower extremities seven times a week as tolerated one time a day. A review of Resident 93's care plan dated September 13, 2017, indicated the resident was at risk for decline ROM and contracture formation due to limited mobility. The care plan goal indicated Resident 93 will maintain current ROM for three months. The interventions indicated to change the resident position every FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 54 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE two hours and as needed, keep resident in good body alignment, and provide RNA program as ordered. A review of the quarterly Joint Mobility Assessment (JMA) dated December 1, 2017, indicated Resident 93 had ROM within functional limitation (variance due to normal aging process allowed) to her left and right hip, knee, elbow, wrist, and hand fingers joints. The JMA also indicated Resident 93 had ROM limitation to her left and right shoulder and ankle joints. A review of Resident 93's Minimum Data Set (MDS a standardized comprehensive assessment and care planning tool) dated December 1, 2017, indicated the resident was rarely/never able to understand others and rarely/never made herself understood. The resident required total assistance with one person physical assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated the resident had functional limitation in ROM to both sides of her upper (shoulder, elbow, wrist, and hand) and lower (hip, knee, ankle, and foot) extremities. On December 21, 2017 at 09:26 a.m., during an observation, Resident 93 was up in her Geri chair, non verbal. Resident 93 had foot drop (describes a difficulty in lifting the front part of the foot). On December 22, 2017 at 02:16 p.m., during an observation in the presence of RNA 2 (assisting), RNA 1 was observed performing PROM exercise Resident 93. RNA 1 was observed to not fully perform PROM as follows: Right and left extremities range of motion RNA 1 did not attempt and/or perform flexion FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 55 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and extension (bending and straightening) of the left and right shoulders and toes; abduction and adduction (moving away and into starting position) of the left shoulder, and left and right hips; ulnar and radial deviation (moving wrist side to side) of the left and right wrists. During observation, Resident 93's had limited ROM to the left and right knees and ankles. On December 22, 2017, during an interview after performing the PROM exercises to Resident 93, RNA 1 stated she did not perform flexion/extension of both shoulders, and abduction/adduction of the left shoulder and both hips. On December 22, 2017 at 9:53 a.m., during an interview in the presence of Occupational Therapist 1 (OT 1), Physical Therapist 1 (PT 1) stated he did not see any problems with the RNAs performing ROM exercises, when conducting random competency skills evaluation of the RNAs. PT 1 and OT 1 stated they instructed the RNAs to provide ROM exercises as follow: flexion/extension of the hip, knee, wrist, ankle, shoulder, elbow, hand digits, and metacarpal (MCP bones of the hand) joints, abduction/adduction of the shoulder and hip joints. PT 1 and OT 1 stated the rehabilitation department did not have a resource material and/or manual on how to perform ROM exercises. PT 1 and OT 1 stated the expectation was for the RNAs to provide ROM exercises to all the resident' joints as instructed. A review of the Facility's undated policy and procedure titled "Range of Motion Exercises" indicated the purpose of the procedure was to exercise the resident's joints and muscles. Review the resident's care plan to assess for any special needs of the resident. Exercise the shoulder, elbow, wrist, thumb, fingers, hip, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 56 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE knee, feet, and toes. Document the date and time the exercise was performed, if and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure, any problems or complaints made by the resident related to the procedure. Notify the charge nurse or supervisor if the resident refuses the exercises. Report other information in accordance with the facility policy and professional standards of practice. A review of the facility's undated policy titled "Comprehensive Person Centered Care Planning Process" indicated the purpose of the policy was to develop and implement a baseline and comprehensive person centered care planning for each resident which meets the standards of quality of care in a timely manner and provided by qualified professionals who are culturally competent. c. A review of Resident 75's admission record indicated an initial admission to the facility on January 9, 2012 and the most recent readmission was on November 11, 2013, with diagnoses including high blood pressure, diabetes mellitus (high blood sugar) and dementia (a persistent disorder of the mental processes). The history and physical dated January 18, 2017 , indicated the resident has above the knee amputation of both legs (legs are missing from above the knees). A review of the physician's orders dated November 8, 2013, indicated the Restorative Nursing Assistant (RNA) was to perform active assisted ROM (AAROM) to both (left and right) lower extremities five times a week as tolerated and passive range of motion (PROM no participation of the resident) exercise to the left hand/fingers seven times a week as tolerated one time a day. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 57 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 75's care plan dated September 13, 2017, indicated the resident was at risk for decline in ROM and contracture formation due to limited mobility. The care plan goal indicated Resident 93 will maintain current ROM for three months. The interventions indicated to change the resident position every two hours and as needed, provide RNA exercises daily as tolerated, and apply hand roll daily. A review of Resident 75's Minimum Data Set (MDS a standardized comprehensive assessment and care planning tool) dated November 16, 2017, indicated the resident had moderate impairment of cognitive skills for daily decision making. The resident required extensive assistance with one person physical assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated the resident had functional limitation in ROM to both sides of his lower (hip, knee, ankle, and foot) extremities and to his upper (shoulder, elbow, wrist, and hand). A review of the Joint Mobility Assessment (JMA) dated November 16, 2017, indicated Resident 75 had ROM within functional limitation (variance due to normal aging process allowed) to his shoulders, hips, knees, elbows, wrists, and hand fingers joints. On December 22, 2017 at 9:53 a.m., during an interview in the presence of the Occupational Therapist (OT 1), the Physical Therapist (PT 1) stated he did not see any problems with the RNAs performing ROM exercises, when conducting random competency skills evaluation of the RNAs. PT 1 and OT 1 stated they instructed the RNAs to provide ROM exercises as follow: flexion/extension of the hip, knee, wrist, ankle, shoulder, elbow, hand digits, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 58 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and metacarpal (MCP bones of the hand) joints, abduction/adduction of the shoulder and hip joints. PT 1 and OT 1 stated the rehabilitation department did not have a resource material and/or manual on how to perform ROM exercises. PT 1 and OT 1 stated the expectation was for the RNAs to provide ROM exercises to all the resident' joints as instructed. On December 27, 2017 at 10:35 a.m., during an observation, RNA 3 was observed performing PROM exercise to Resident 75's hip and left hand fingers. RNA 3 did not attempt and/or perform flexion and extension (bending and straightening) of the left and right knees. Resident 75's left fourth and fifth fingers were contracted (unable to extend fingers). On December 27, 2017 at 10:55 a.m., during an interview, RNA 3 stated Resident 75 had full ROM to his left hand fingers. RNA 3 stated she did not perform ROM to Resident 75's knees. On December 27 at 11:09 a.m., during an interview in the presence of RNA 3, Resident 75 stated he lost ROM of his 4th and 5th left fingers about two and half years ago due to a stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or ruptures). Resident 75 stated he was unable to use his 3rd, 4th, and 5th left fingers. When asked to demonstrate his left fingers ROM, Resident 75 was able to partially extend his left 3rd finger, and was not able to extend his left 4th and 5th fingers. On December 27, 2017 at 12:01 p.m., during an interview, Occupational Therapist 1 (OT 1) stated Resident 75's proximal interphalangeal joints (the joints between the bones of the fingers) of the left hand third, fourth, and fifth FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 59 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE fingers were contracted. OT 1 stated she missed to document the fingers contractures. A review of the Facility's undated policy and procedure titled "Range of Motion Exercises" indicated the purpose of the procedure was to exercise the resident's joints and muscles. Review the resident's care plan to assess for any special needs of the resident. Exercise the shoulder, elbow, wrist, thumb, fingers, hip, knee, feet, and toes. Document the date and time the exercise was performed, if and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure, any problems or complaints made by the resident related to the procedure. Notify the charge nurse or supervisor if the resident refuses the exercises. Report other information in accordance with the facility policy and professional standards of practice. A review of the facility's undated policy titled "Comprehensive Person Centered Care Planning Process" indicated the purpose of the policy was to develop and implement a baseline and comprehensive person centered care planning for each resident which meets the standards of quality of care in a timely manner and provided by qualified professionals who are culturally competent. On December 22, 2017 at 9:53 a.m., during an interview in the presence of Occupational Therapist 1 (OT 1), Physical Therapist 1 (PT 1) stated he did not see any problems with the RNAs performing ROM exercises, when conducting random competency skills evaluation of the RNAs. PT 1 and OT 1 stated they instructed the RNAs to provide ROM exercises as follow: flexion/extension of the hip, knee, wrist, ankle, shoulder, elbow, hand digits, and metacarpal (MCP-bones of the hand) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 60 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE joints, abduction/adduction of the shoulder and hip joints. PT 1 and OT 1 stated the rehabilitation department did not have a resource material and/or manual on how to perform ROM exercises. PT 1 and OT 1 stated the expectation was for the RNAs to provide ROM exercises to all the resident' joints as instructed. A review of the Facility's undated policy and procedure titled "Range of Motion Exercises" indicated the purpose of the procedure was to exercise the resident's joints and muscles. Review the resident's care plan to assess for any special needs of the resident. Exercise the shoulder, elbow, wrist, thumb, fingers, hip, knee, feet, and toes. Document the date and time the exercise was performed, if and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure, any problems or complaints made by the resident related to the procedure. Notify the charge nurse or supervisor if the resident refuses the exercises. Report other information in accordance with the facility policy and professional standards of practice. A review of the facility's undated policy titled "Comprehensive Person-Centered Care Planning Process" indicated the purpose of the policy was to develop and implement a baseline and comprehensive person-centered care planning for each resident which meets the standards of quality of care in a timely manner and provided by qualified professionals who are culturally competent. c. A review of Resident 75's admission record indicated an initial admission to the facility on January 9, 2012 and the most recent readmission was on November 11, 2013, with diagnoses including high blood pressure and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 61 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE acquired absence of left and right legs. A review of the physician's orders dated November 8, 2013, indicated the Restorative Nursing Assistant (RNA) was to perform active assisted ROM (AAROM) to both (left and right) lower extremities five times a week as tolerated and passive range of motion (PROM - no participation of the resident) exercise to the left hand/fingers seven times a week as tolerated one time a day. A review of Resident 75's care plan dated September 13, 2017, indicated the resident was at risk for decline in ROM and contracture formation due to limited mobility. The care plan goal indicated Resident 93 will maintain current ROM for three months. The interventions indicated to change the resident position every two hours and as needed, provide RNA exercises daily as tolerated, and apply hand roll daily. A review of Resident 75's Minimum Data Set (MDS - a standardized comprehensive assessment and care planning tool) dated November 16, 2017, indicated the resident had moderate impairment of cognitive skills for daily decision making. The resident required extensive assistance with one person physical assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated the resident had functional limitation in ROM to both sides of his lower (hip, knee, ankle, and foot) extremities and to his upper (shoulder, elbow, wrist, and hand). A review of the Joint Mobility Assessment (JMA) dated November 16, 2017, indicated Resident 75 had ROM within functional limitation (variance due to normal aging process allowed) to his shoulders, hips, knees, elbows, wrists, and hand fingers joints. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 62 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On December 22, 2017 at 9:53 a.m., during an interview in the presence of the Occupational Therapist (OT 1), the Physical Therapist (PT 1) stated he did not see any problems with the RNAs performing ROM exercises, when conducting random competency skills evaluation of the RNAs. PT 1 and OT 1 stated they instructed the RNAs to provide ROM exercises as follow: flexion/extension of the hip, knee, wrist, ankle, shoulder, elbow, hand digits, and metacarpal (MCP-bones of the hand) joints, abduction/adduction of the shoulder and hip joints. PT 1 and OT 1 stated the rehabilitation department did not have a resource material and/or manual on how to perform ROM exercises. PT 1 and OT 1 stated the expectation was for the RNAs to provide ROM exercises to all the resident' joints as instructed. On December 27, 2017 at 10:35 a.m., during an observation, RNA 3 was observed performing PROM exercise to Resident 75's hip and left hand fingers. RNA 3 did not attempt and/or perform flexion and extension (bending and straightening) of the left and right knees. Resident 75's left fourth and fifth fingers were contracted (unable to extend fingers). On December 27, 2017 at 10:55 a.m., during an interview, RNA 3 stated Resident 75 had full ROM to his left hand fingers. RNA 3 stated she did not perform ROM to Resident 75's knees. On December 27 at 11:09 a.m., during an interview in the presence of RNA 3, Resident 75 stated he lost ROM of his 4th and 5th left fingers about two and half years ago due to a stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or ruptures). Resident 75 stated he was unable to use his 3rd, 4th, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 63 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 5th left fingers. When asked to demonstrate his left fingers ROM, Resident 75 was able to partially extend his left 3rd finger, and was not able to extend his left 4th and 5th fingers. On December 27, 2017 at 12:01 p.m., during an interview, Occupational Therapist 1 (OT 1) stated Resident 75's proximal interphalangeal joints (the joints between the bones of the fingers) of the left hand third, fourth, and fifth fingers were contracted. OT 1 stated she missed to document the fingers contractures. A review of the Facility's undated policy and procedure titled "Range of Motion Exercises" indicated the purpose of the procedure was to exercise the resident's joints and muscles. Review the resident's care plan to assess for any special needs of the resident. Exercise the shoulder, elbow, wrist, thumb, fingers, hip, knee, feet, and toes. Document the date and time the exercise was performed, if and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure, any problems or complaints made by the resident related to the procedure. Notify the charge nurse or supervisor if the resident refuses the exercises. Report other information in accordance with the facility policy and professional standards of practice. A review of the facility's undated policy titled "Comprehensive Person-Centered Care Planning Process" indicated the purpose of the policy was to develop and implement a baseline and comprehensive person-centered care planning for each resident which meets the standards of quality of care in a timely manner and provided by qualified professionals who are culturally competent. d. A review of the admission record indicated Resident 4 was originally admitted to the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 64 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on January 1, 2009 and readmitted on September 13, 2016 with diagnoses that included convulsions, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and dementia (loss of memory and other mental abilities severe enough to interfere with daily life). The Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool), dated September 18, 2017, indicated Resident 4's cognition was severely impaired in daily decision-making. According to the MDS, the resident was assessed as needing full staff assistance with eating, toilet use, personal hygiene, and bathing, transferring, and requiring extensive assistance with bed mobility and dressing. A review of Resident 4's plan of care dated March 23, 2017, indicated the resident's right hand was at risk for further limited range of motion due to poor positioning and indicated a goal to maintain the resident's current ROM of right hand/fingers and prevent further limited range of motion. The care plan interventions indicated the RNA to apply right hand splint for at least four to six hours or as tolerated with skin check, then apply right hand roll upon removal of splint done daily seven times per week. A review of Resident 4's physician's order dated September 18, 2017 indicated RNA to apply right hand splint for at least four to six hours or as tolerated with skin check, then apply right hand roll upon removal of splint done daily seven times per week. On December 20, 2017 at 9:24 a.m., during an observation, Resident 4 was lying in bed with no hand splint or hand roll. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 65 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On December 20, 2017 at 4:20 p.m., during an interview, the Registered Nurse 2 (RN 2) verified that there were no hand rolls in the morning. RN 2 stated the hand rolls were supposed to be applied by the RNA. A review of a document titled "Restorative Nursing Orders" indicated the following: 1. The RNA to apply bilateral Thera boots for four to six hours or as patient tolerated every day seven times per week. The document indicated no signature on November 24, 2017; October 2 to October 3, 2017; October 15, 2017; October 18, 2017; September 10, 2017; September 15, 2017; September 17, 2017; September 23, 2017; August 15, 2017; August 23, 2017, July 23, 2017; and July 27 to July 28, 2017 for day shift to indicate the bilateral Thera boots were applied for the resident. 2. RNA to apply right hand splint for at least four to six hours or as tolerated with skin check, then apply right hand roll upon removal of splint done daily seven times per week one time a day. The document did not have a RNA signature on October 2 to October 3, 2017; October 15, 2017; October 18, 2017; September 23, 2017; August 15, 2017; August 23, 2017, July 23, 2017; and July 27 to July 28, 2017 for day shift to indicate the right hand splint and hand roll were applied as ordered by the physician. 3. RNA to do passive range of motion (PROM) to bilateral upper extremities (BUE) and bilateral lower extremities (BLE) seven times per week as tolerated one time a day. There was no documentation by RNA to indicate the exercise was performed on October 2 to October 3, 2017; October 15, 2017; October 18, 2017; September 10, 2017; September 15, 2017; September 17, 2017; September 23, 2017; August 15, 2017; August 23, 2017, July FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 66 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 23, 2017; and July 27 to July 28, 2017. A review of the undated policy and procedure and titled "Charting and Documentation," indicated all observation, medications administered, services performed, etc., must be documented in the resident's clinical records.

F697 SS=D Pain Management CFR(s): 483.25(k)

F697 01/17/2018 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the nursing staff failed to monitor and provide pain management for two of 35 sampled residents (Residents 1 and 107), who was experiencing pain during range of motion (ROM - the extent of movement of a joint) exercise. This deficient practice had the potential for residents to experience unnecessary pain. Findings: a. A review of Resident 107's admission record indicated an initial admission to the facility on June 14, 2016 and the most recent readmission dated October 31, 2017, with diagnoses including abnormal posture, osteoporosis (a bone disease that occurs when the body loses too much bone makes too little bone, or both), and high blood pressure. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 67 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 107's Minimum Data Set (MDS - a standardized comprehensive assessment and care planning tool) dated September 12, 2017, indicated the resident was rarely able to understand others and rarely made herself understood. The resident required total assistance with one person physical assistance with bed mobility, toilet use, and personal hygiene. The MDS also indicated that Resident 107 did not have indicators of pain or possible pain. A review of the Resident 107's physician's orders indicated the followings: 1. Acetaminophen (Tylenol) tablet 325 milligrams (mg), give 650 mg via gastrostomy tube (GT- a tube inserted into the stomach through a surgical incision use for feeding and administration of medication for a resident unable to swallow) every four hours as needed for mild pain (pain level one to three on a zero to 10 pain rating scale), dated October 31, 2017. 2. Restorative Nursing Assistant (RNA) to perform passive range of motion (PROM - no participation of the resident) exercise to both (right and left) upper extremities and lower extremities seven times a week or as tolerated, dated November 1, 2017. A review of Resident 107's care plan revised on November 1, 2017, indicated the resident had the potential for alteration in comfort/potential for pain related to osteoporosis. The care plan goal indicated the resident will be relieved within one hour of intervention for three months. The interventions indicated to administer medications as ordered, assess pain symptoms, and identify frequency, location, quality, onset and manner of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 68 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE expressing pain. A review of Resident 107's care plan dated November 15, 2017, indicated the resident had potential for further contracture related to impaired mobility. The goal indicated the resident will have no further contracture in the next three months. The care plan interventions indicated to keep contracted areas clean and other free and odor free, monitor for pain or increased stiffness, and perform ROM as ordered. A review of Resident 107's RNA weekly progress notes dated November 15, 2017, indicated the resident's overall participation was uncooperative and her overall tolerance to the ROM exercises was fair. A review of Resident 107's RNA weekly progress notes dated December 14, 2017, indicated that the resident overall participation was combative and her tolerance fair. On December 21, 2017 at 02:01 p.m., during an observation in the presence of RNA 1 (assisting), RNA 2 performed PROM exercises to Resident 107's upper and lower extremities. Resident was grimacing and moaning at times during ROM exercises. On December 27, 2017 at 08:10 a.m., during a phone interview, Resident 107's family member (FM 1) stated that Resident 107 had been more on the fetal position (in this position, the back is curved, the head is bowed, and the limbs are bent and drawn up to the torso) since insertion of the GT. FM 1 stated that each time she visited (last visit two days ago), Resident 107 appeared uncomfortable. FM 1 also stated that she did not know if Resident 107 was receiving pain medication. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 69 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On December 27, 2017 at 9:19 a.m., during an observation, RNA 3 was observed performing PROM exercise to Resident 107. Resident 107 was opening her eyes and mouth wide and pulling back her extremities during ROM exercises. A review of Resident 107's Medication Administration Record (MAR) for the months of November 2017 and December 2017, did not indicated that the resident received Tylenol as needed for pain. On December 27, 2017 at 9:53 a.m., during an interview, Licensed Vocational Nurse 1 stated that she reviewed Resident 107's MAR for the month of December 2017 and could not find documented evidence the resident received pain medication (Tylenol) before, during, or after ROM exercise. LVN 1 also stated the RNAs were not documenting the specific time they performed ROM exercise to the residents. On December 28, 2017 at 9:13 a.m., during an interview, the Director of Nursing (DON) stated that the RNAs were instructed to stop performing ROM exercise if a resident was experiencing pain during the exercise, and notify the charge nurse. The DON stated that she reviewed Resident 107's MAR dated December 21, 2017, and could not find documented evidence Resident 107 received Tylenol (for mild pain) around the time of the ROM exercises (2:01 p.m.). The DON also stated that she reviewed the nurses' notes and could not find documented evidence RNA 2 reported the resident's pain to the charge nurse. On December 28, 2017 at 12:31 p.m., during a follow-up interview, LVN 1 stated that she reviewed Resident 107's care plan for contracture prevention dated November 15, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 70 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2017 and could not find documented evidence the licensed nursing staff and the RNAs were monitoring for pain and/or stiffness as indicated in the care plan intervention. On December 28, 2017 at 3:20 p.m., during an interview, PT 1 stated that it was the expectation of the RNA to notify charge nurse if a resident experienced pain or stiffness, and/or exhibited resistive behavior during ROM exercises. A review of the facility's undated policy and procedure titled "Range of Motion Exercises" indicated that the purpose of the procedure was to exercise the resident's joints and muscles. Review the resident's care plan to assess for any special needs of the resident. Document the date and time the exercise was performed, if and how the resident participated in the procedure or any changes in resident's ability to participate in the procedure, any problems or complaints made by the resident related to the procedure. Notify the charge nurse or supervisor if the resident refuses the exercises. Report other information in accordance with the facility policy and professional standards of practice. b. According to the admission record, Resident 1 was admitted to the facility on November 22, 2012 and readmitted on December 14, 2017, with diagnoses that included chronic obstructive pulmonary disease (a lung disease characterized by long-term poor airflow), hypertension (high blood pressure), and Alzheimer's disease (progressive mental deterioration). A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated September 5, 2017, indicated the resident's cognitive skills (mental action or process of acquiring knowledge and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 71 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE understanding) for daily decision-making was severely impaired. The resident required extensive one-person physical assistance with bed mobility and dressing. The MDS indicated the resident was fully dependent on staff for eating, toilet use, bathing, and personal hygiene. A review of Resident 1's physician order indicated the following: 1. Monitor for pain level every shift using pain scale zero to ten: zero equal to no pain; one to three equal to mild pain; four to seven equal to moderate pain; eight to ten equal to severe pain, dated October 14, 2015. 2. Tylenol 650 milligram (mg) two tablets via gastrostomy (GT- a surgical procedure for inserting a tube directly into the stomach through the abdomen wall incision for administration of food, fluids, and medications) tube every four hours as needed for mild pain, dated October 14, 2015. A review of the Physician's Orders dated February 23, 2017 indicated an order for Restorative Nursing Assistant (RNA) once a day for seven times a week for gentle passive range of motion (PROM-how far someone else can move your joint if you are completely relaxed) exercises for both lower and upper extremities as tolerated. On December 28, 2017 at 9:22 a.m., RNA 4 was observed providing PROM to Resident 1 while resident was in bed. Resident 1 was lying in bed, eyes open, grimacing, and unable to verbalize needs. RNA 4 asked the resident if was in pain but the resident did not speak. RNA 4 continued to perform PROM of resident's both upper extremities and right lower extremity. Resident 1 was observed kicking his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 72 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE left leg when the RNA tried to continue performing PROM. The resident also did not open his clenched left fist. On December 28, 2017 at 9:42 a.m., during an interview with RNA 4, she stated she asked the charge nurse whether the resident received pain medication prior to starting the PROM. RNA 4 stated the charge nurse did not give pain medication. RNA 4 further stated she was told by the charge nurse to let her know if the resident was having pain during the PROM exercises. RNA stated she did not know if the resident has any pain medication ordered. On December 28, 2017 at 10:08 a.m., during an interview with the licensed vocational nurse 7 (LVN 7) taking care of the resident, she stated the resident had Tylenol 650 mg order for mild pain. LVN 7 also stated, the last time the resident received the pain medication was on December 14, 2017 at 9:16 p.m. LVN 7 stated the resident did not receive any pain medication prior to ROM exercise because when she assessed him he did not have any pain on his face and the RNA had not reported to her the resident was having pain during and after ROM exercises. On December 28, 2017 at 10:08 a.m., during a concurrent interview and record review, LVN 7 stated the resident tended to have anxiety and kick when he was given care. LVN 7 also stated Resident 1 was on Ativan (antianxiety) 1 mg every 8 hours as need for anxiety manifested by punching and kicking nurses during care. LVN 7 stated the last time the resident received Ativan was on December 16, 2017 at 9 p.m. for punching and kicking nurses. On December 28. 2017 at 10:56 a.m., during an interview, RNA 4 stated Resident 1 sometimes kicks during ROM exercises. RNA 4 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 73 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE also stated she worked four to five days a week with the resident. RNA 4 stated the resident was kicking during the ROM "because he was in pain." RNA 4 further stated the resident kicked two out of four or five days of the week she works with him. A review of Resident 1's RNA Weekly Summary dated December 23, 2017, November 17, 2017, and November 1, 2017 indicated the resident did not complain of pain during ROM exercises. On December 28, 2017 at 11:05 a.m., during an interview and record review with the Registered Nurse 2 (RN 2), she stated the MAR for November 2017 indicated, the resident exhibited multiple days (13 days) of kicking staff during care. The MAR indicated the resident did not receive Tylenol or any other pain medication for the month of November 2017. A review of Resident 1's care plan initiated on December 15, 2017 indicated the resident was in need of both upper and lower extremity range of motion as manifested by risk for decline in range of motion. Another care plan initiated on November 14, 2017 indicated the resident was at risk for decline in range of motion and contracture formation due to impaired mobility. The care plan interventions did not address pain.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 01/17/2018 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 74 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to check one out of 35 sampled residents (Resident 6) blood pressure prior to the administration of isosorbide dinitrate (medication to treat hypertension (HTN elevated blood pressure). This deficient practice had the potential to result in ineffectively managed hypertension for Resident 6 and may cause a harmful significant drop in the blood pressure. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 75 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 6's Admission Record indicated the resident was originally admitted to the facility on July 22, 2008 and readmitted on September 14, 2017, with a diagnosis of, but not limited to, hypertension. A review of Resident 6's Quarterly Minimum Data Set (MDS - a standardized assessment and screening tool) dated September 21, 2017, indicated the resident has severe cognitive skills for daily decision-making, rarely/never makes self-understood, and rarely/never able to understand others. The tool indicated the resident is totally dependent with transfers, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 6's Order Summary Report indicated a physician's order dated October 23, 2017 to administer isosorbide dinitrate 30 milligrams (mg) one (1) tablet by mouth in the morning for HTN, hold (don't administer) if systolic blood pressure (SBP indicates how much pressure your blood is exerting against your artery walls when the heart beats) is less than 100. During an interview with Licensed Vocational Nurse 3 (LVN 3) on December 28, 2017 at 12:33 p.m., and a concurrent review of Resident 6's Medication Administration Record (MAR) and Medication Administration Notes for December 6, December 26, and December 27, 2017 addressing isosorbide administration, LVN 3 stated there were no other Medication Administration Notes indicating BP levels were checked prior to giving isosorbide medication. When asked about the relevance of checking Resident 6's blood pressure prior to administering isosorbide, LVN 3 stated they need to follow the parameter per physician order. When asked about the risk of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 76 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE administering isosorbide without checking the BP, LVN 3 stated it is unknown if the medication is effective and if Resident 6's initial BP was low, there's a risk for hypotension (abnormally low blood pressure). A review of the facility's undated policies and procedures titled "Administering Medications," indicated medications shall be administered in a safe and timely manner, and as prescribed. The policies and procedures indicated medications must be administered in accordance with the orders, including any required time frame. The policies and procedures also indicated that vital signs (if necessary) must be checked/verified for each resident prior to administering medications.

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 01/17/2018 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 77 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to: 1. Have a system of monitoring the Medication Room temperature of one (1) out of the two (2) medication room storage. This deficient practice had the potential for loss of efficacy of the medications stored outside the required room temperature range. 2. Ensure the opened (in-use) Lantus SoloStar insulin (medication to manage diabetes [high blood sugar]) was stored at room temperature per manufacturer's guidelines. The facility also failed to indicate on the Lantus SoloStar insulin the "opened date" to readily identify the expiration date for one (1) out of the 35 sampled residents (Resident 41). This deficient practice had the potential for loss of efficacy of Resident 41's Lantus SoloStar insulin and unintentional medication administration of possibly expired medication. Findings: a. During the Medication Room inspection and observation on December 20, 2017 at 10:41 a.m., and a concurrent interview with Registered Nurse 1 (RN 1), the Medication Room for Station 1 where house supply of medications are stored did not have a thermometer. There was no system in place to check the room temperature if the medications FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 78 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE are being stored at a safe temperature level. RN 1 stated they do not monitor the room temperature in the Medication Room for Station 1. A review of the facility's undated policies and procedures titled "Storage of Medications" indicated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. b. A review of Resident 41's Admission Record indicated the resident was originally admitted to the facility on October 12, 2017, with a diagnosis of, but not limited to, type 2 diabetes mellitus (DM - high blood sugar). A review of Resident 41's Admission Minimum Data Set (MDS- a standardized assessment and screening tool) dated October 19, 2017, indicated the resident has intact cognition, is able to make self-understood, and is able to understand others. The tool indicated the resident needs limited assistance with walking, toilet use and personal hygiene and needs extensive assistance with bed mobility, transfers, locomotion, dressing, and eating. A review of Resident 41's Order Summary Report indicated a physician's order dated October 12, 2017, to administer Lantus Insulin (Insulin Glargine - lowers the level of glucose [sugar] in the blood by helping glucose enter the body's cells) inject 60 units subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) in the evening for DM. During the Medication Room inspection and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 79 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE observation on December 20, 2017 at 11:13 a.m., in the presence of Registered Nurse 1 (RN 1), the Lantus SoloStar prefilled pen ordered for Resident 41 from the refrigerator had a manufacturer's label that indicated a full prefilled pen should have a total of 300 units. Resident 41's Lantus SoloStar pen had 80 units left. Resident 41's Lantus SoloStar pen did not indicate the date on when it was opened to readily identify on when it should be discarded. During an interview with RN 1 on December 20, 2017 at 11:26 a.m., RN 1 stated the licensed nurse should have written the date on when Resident 41's Lantus SoloStar pen was opened. When asked on the consequence of not writing the opened date, RN 1 stated that they don't know the expiration date of the insulin and so there's a risk for side effects. A review of the facility's undated policies and procedures titled "Administering Medications," indicated medications shall be administered in a safe and timely manner, and as prescribed. The policies and procedures indicated to place the date on the container when opening a multi-dose container. A review of the facility's undated policies and procedures titled "Insulin, Storage/Expiration of," indicated the policy in keeping with good pharmaceutical practice, to maintain proper storage and monitor expiration of insulin. All insulin vials, cartridge and pen of insulin must be dated when opened. As a general policy, insulin in use, regardless of storage, must be discarded after four (4) weeks. Whenever possible and applicable, facility shall follow storage recommendations by manufacturers or producers of insulin brands. Licensed nurses must monitor insulin vials for expiration, during medication administration and routine FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 80 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication inspection or review. Director of Nurses and/or designee shall include in his/her monthly medication triple check, monitoring of insulin vials for expiration. Expired insulin vials shall be discarded. A review of Lantus manufacturer's literature revised in March 2007 indicated an open (inuse) SoloStar disposable insulin device should not be refrigerated but should be kept at room temperature (below 86 degrees Fahrenheit [30 degrees Celsius]) away from direct heat and light. The opened SoloStar kept at room temperature must be discarded after 28 days.

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 01/23/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 81 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, the facility failed to ensure the dietary staff stored and prepared food under sanitary conditions. These deficient practices placed the residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: On December 19, 2017 at 7:23 a.m., during an initial tour of the kitchen accompanied by Dietary Service Supervisor (DSS), the following findings were observed: 1. In the walk in freezer, there was a bowl of sauce covered with saran wrap dated December 15, 2017. The DSS stated the food was no good and had to be discarded. 2. A used brush covered with saran wrap found in the walk in refrigerator. The DSS stated the brush used to make bean roll. The DSS also stated the brush should not be in the refrigerator. 3. Used plastics of sliced bread with no open date found in the walk in refrigerator. 4. One romaine lettuce in a white bin with no cover or label. The DSS stated the lettuce should have been covered and dated. 5. A bag of seven oranges on top of a white bin in the walk in refrigerator. The DSS stated the oranges belonged to an employee who left it there and forgot it. The DSS stated any employee foods should not be stored in the walk in refrigerator. 6. Lemons were found in white Styrofoam plate covered with saran wrap. The DSS stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 82 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE lemons belonged to an employee. The DSS also stated the lemons should not be stored in the freezer. 7. Three trays of cups filled with milk with no label and no date found in the health shake and milk/juice refrigerator. 8. Three trays of cups filled with apple, orange, and fruit punch juice found in the health shake and milk/juice refrigerator. The DSS stated the milk and juice were from the morning. She also stated they should have been dated and labeled. 9. Freezer one (Meat & Ice cream freezer) contained: " One bag of roast beef with no date of delivery " One bag of tilapia and one bag of beef bones with no label and no date " Four bags of sliced ham with no label and no date of delivery in a white container " One box of five pounds chicken leg with no date of delivery " Six bags 60 pounds boneless meat with no date of delivery. The DSS stated the meat were delivered on Friday. She further stated that the bag should be dated and labeled. 10. The pot sink contained a soiled white linen soaked in water in a white bin. The DSS stated the linen should not be in the pot sink. The DSS also stated they would remove the bin containing the soaked linen.

F842 SS=B Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 01/23/2018 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 83 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 84 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for two (2) out of the 35 sampled residents (Resident 41 and Resident 88) by: 1. Failing to ensure Resident 41's physician had signed and dated the Physician Orders for Life-Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration) in a timely manner. 2. Failing to ensure Resident 88's consent form FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 85 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for Lexapro (a medication used to treat anxiety in adults and major depression in adults and adolescents) was complete with the signature of the physician. This deficient practice had the potential to result in confusion in the care and services for Resident 41 and Resident 88 and placed the resident at risk of receiving unwanted treatment and not receiving appropriate care based on her wishes due to incomplete resident medical care information. Findings: a. A review of Resident 41's Admission Record indicated the resident was originally admitted to the facility on October 12, 2017. A review of Resident 41's Order Summary Report indicated the resident has diagnoses of, but not limited to, history of transient ischemic attack (TIA - also called a mini-stroke, is a neurological event with the signs and symptoms of a stroke [the sudden death of brain cells in a localized area due to inadequate blood flow], but which go away within a short period of time), cerebral infarction (a brain lesion in which a cluster of brain cells die when they don't get enough blood), hypertension (elevated blood pressure), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Resident 41's Admission Minimum Data Set (MDS- a standardized assessment and screening tool) dated October 19, 2017, indicated the resident has intact cognition, is able to make self understood, and is able to understand others. The tool indicated the resident needs limited assistance with walking, toilet use and personal hygiene and needs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 86 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE extensive assistance with bed mobility, transfers, locomotion, dressing, and eating. A review of Resident 41's Physician Orders for Life-Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST form is not an advance directive.) prepared on October 13, 2017 by Director of Social Services (DSS), indicated that having the physician sign indicates to the best of the physician's knowledge that the orders are consistent with the patient's medical condition and preferences. The POLST did not have the signature of Resident 41's physician. During an interview with Licensed Vocational Nurse 1 (LVN 1), on December 28, 2017 at 8:54 a.m., while LVN 1 reviewed Resident 41's records, LVN 1 stated that when the resident's physician comes to the facility, the physician should sign the form. LVN 1 stated the nursing staff and medical records should remind the doctor and check if everything that required signing was signed. According to the National POLST Paradigm, since the POLST is a medical order, a healthcare professional is required to sign it in order for it to be valid. The form has a statement saying that, by signing the form, the healthcare professional agrees that the orders on the form match what treatments the patient said he/she wanted during a medical emergency based on his/her medical condition today (http://www.ohsu.edu/polst/). b. A review of the admission record indicated Resident 88 was admitted on October 3, 2017, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 87 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with diagnoses including diabetes mellitus (a group of diseases that result in too much sugar in the blood), and major depression. A review of Resident 88's history and physical examination dated October 5, 2017, indicated the resident had the capacity to understand and make decisions. A review of Resident 88's physician order indicated Lexapro 20 milligram (mg), 1 tablet was to be given by mouth daily for depression manifested by verbalization of sad feeling. A review of the Informed Consent Verification form dated October 3, 2017, indicated the physician was to verify he obtained consent for the use of Lexapro (an antidepressant medication) by filling out and signing the consent form. However, the physician's signature section of the consent form was blank. A review of the Medication Administration Record (MAR) indicated Resident 88 received Lexapro 20 mg every day at 9 a.m., from October 4, 2017 to December 21, 2017. On December 21, 2017 at 3:52 p.m. during an interview, the Registered Nurse (RN 2) confirmed there was no physician signature on the consent form for Lexapro. RN 2 stated the consent form should have been signed by the physician. A review the facility's undated policy and procedure regarding informed consent indicated the physician was to review and sign informed consent verification form when in facility. The facility licensed staff verifies that informed consent has been obtained before the orders are carried out by the nursing staff. The licensed staff verifying that consent has been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 88 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE obtained, signs the informed consent verification form.

F842 SS=B Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 01/23/2018 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 89 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for two (2) out of the 35 sampled residents (Resident 41 and Resident 88) by: 1. Failing to ensure Resident 41's physician had signed and dated the Physician Orders for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 90 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Life-Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration) in a timely manner. 2. Failing to ensure Resident 88's consent form for Lexapro (a medication used to treat anxiety in adults and major depression in adults and adolescents) was complete with the signature of the physician. This deficient practice had the potential to result in confusion in the care and services for Resident 41 and Resident 88 and placed the resident at risk of receiving unwanted treatment and not receiving appropriate care based on her wishes due to incomplete resident medical care information. Findings: a. A review of Resident 41's Admission Record indicated the resident was originally admitted to the facility on October 12, 2017. A review of Resident 41's Order Summary Report indicated the resident has diagnoses of, but not limited to, history of transient ischemic attack (TIA - also called a mini-stroke, is a neurological event with the signs and symptoms of a stroke [the sudden death of brain cells in a localized area due to inadequate blood flow], but which go away within a short period of time), cerebral infarction (a brain lesion in which a cluster of brain cells die when they don't get enough blood), hypertension (elevated blood pressure), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 91 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 41's Admission Minimum Data Set (MDS- a standardized assessment and screening tool) dated October 19, 2017, indicated the resident has intact cognition, is able to make self understood, and is able to understand others. The tool indicated the resident needs limited assistance with walking, toilet use and personal hygiene and needs extensive assistance with bed mobility, transfers, locomotion, dressing, and eating. A review of Resident 41's Physician Orders for Life-Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST form is not an advance directive.) prepared on October 13, 2017 by Director of Social Services (DSS), indicated that having the physician sign indicates to the best of the physician's knowledge that the orders are consistent with the patient's medical condition and preferences. The POLST did not have the signature of Resident 41's physician. During an interview with Licensed Vocational Nurse 1 (LVN 1), on December 28, 2017 at 8:54 a.m., while LVN 1 reviewed Resident 41's records, LVN 1 stated that when the resident's physician comes to the facility, the physician should sign the form. LVN 1 stated the nursing staff and medical records should remind the doctor and check if everything that required signing was signed. According to the National POLST Paradigm, since the POLST is a medical order, a healthcare professional is required to sign it in order for it to be valid. The form has a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 92 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE statement saying that, by signing the form, the healthcare professional agrees that the orders on the form match what treatments the patient said he/she wanted during a medical emergency based on his/her medical condition today (http://www.ohsu.edu/polst/). b. A review of the admission record indicated Resident 88 was admitted on October 3, 2017, with diagnoses including diabetes mellitus (a group of diseases that result in too much sugar in the blood), and major depression. A review of Resident 88's history and physical examination dated October 5, 2017, indicated the resident had the capacity to understand and make decisions. A review of Resident 88's physician order indicated Lexapro 20 milligram (mg), 1 tablet was to be given by mouth daily for depression manifested by verbalization of sad feeling. A review of the Informed Consent Verification form dated October 3, 2017, indicated the physician was to verify he obtained consent for the use of Lexapro (an antidepressant medication) by filling out and signing the consent form. However, the physician's signature section of the consent form was blank. A review of the Medication Administration Record (MAR) indicated Resident 88 received Lexapro 20 mg every day at 9 a.m., from October 4, 2017 to December 21, 2017. On December 21, 2017 at 3:52 p.m. during an interview, the Registered Nurse (RN 2) confirmed there was no physician signature on the consent form for Lexapro. RN 2 stated the consent form should have been signed by the physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 93 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review the facility's undated policy and procedure regarding informed consent indicated the physician was to review and sign informed consent verification form when in facility. The facility licensed staff verifies that informed consent has been obtained before the orders are carried out by the nursing staff. The licensed staff verifying that consent has been obtained, signs the informed consent verification form.

F911 SS=B Bedroom Number of Residents CFR(s): 483.90(e)(1)(i)

F911 §483.90 (e)(1) Bedrooms must §483.90(e)(1)(i) Accommodate no more than four residents. For facilities that receive approval of construction or reconstruction plans by State and local authorities or are newly certified after November 28, 2016, bedrooms must accommodate no more than two residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that four (4) out of the 38 resident rooms (Room 108 occupied by Residents 48, 32, 6, 81 and 56; Room 218 occupied by Residents 43, 42, 22 and 65; Room 219 occupied by Residents 54, 99, 37 and 49; and Room 312 occupied by Residents 17, 107, 9, 51 and 79) accommodated no more than four residents per room. These had five (5) beds inside the rooms. Findings: On December 21, 2017 at 3:49 p.m., during the room observation, Room 108 was observed to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 94 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE have five (5) beds each occupied by noninterviewable residents (Residents 48, 32, 6, 81 and 56). Certified Nursing Assistant 2 (CNA 2) was observed providing care to Resident 6. CNA 2 had sufficient space to care for Resident 6. The room observation showed the room had spaces for the residents' beds, overbed tables, bedside tables, tube feeding pumps (for Residents 32 and 56) and personal belongings. There was sufficient space for provisions of necessary care and services and for the residents to move freely inside the room. During an interview with CNA 2 on December 21, 2017 at 4:07 p.m., CNA 2 stated she does not have any issues with regard to the room space while she is providing care to the residents. During an observation and a concurrent interview with Certified Nursing Assistant 3 (CNA 3), on December 21, 2017 at 3:58 p.m., CNA 3 was observed attending to Residents 48 and 32 with no issues observed in relation to the space and provision of care. CNA 3 stated he has no issues related to the space while providing care to both residents. On December 27, 2017 at 9:21 a.m., during the room observation, Room 312 was observed to have five (5) beds assigned to Residents 17, 107, 9, 51 and 79. Restorative Nursing Assistant 3 (RNA 3) was observed providing range of motion exercises to Resident 107. The room observation showed the room had spaces for the residents' beds, tables, cabinets, chairs, tube feeding pump (for Resident 107) and personal belongings, and there was sufficient space for provisions of necessary care and services. During an interview with RNA 3 on December 27, 2017 at 9:41 a.m., RNA 3 stated she has FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 95 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE no issues in regards to the space while providing RNA services to all five residents in Room 312. During an interview with Certified Nursing Assistant 1 (CNA 1) on December 27, 2017 at 9:50 a.m., CNA 1 stated she has been taking care of residents who have occupied Room 312 and she has had enough space to care for the residents. On December 27, 2017 at 9:50 a.m., during the room observation, Room 218 was observed to have five (5) beds assigned to Residents 43, 42, 22 and 65. The resident assigned to Bed A was out of the facility. Observed Certified Nursing Assistant 4 (CNA 4) providing care to Resident 43 with no issues observed in relation to the space and provision of care. The room observation showed the room had spaces for the beds, tables, cabinets, chairs, tube feeding pump (for Resident 42) and personal belongings, and there was sufficient space for provisions of necessary care and services and for the residents to move freely inside the room. During an interview with CNA 4 on December 27, 2017 at 9:51 a.m., CNA 4 stated he has been taking care of residents who have occupied Room 218 and he has had no issues with the space while providing care to the residents. On December 27, 2017 at 9:59 a.m., during the room observation, Room 219 was observed to have five (5) beds assigned to Residents 54, 99, 37 and 49. Bed B was vacant. Certified Nursing Assistant 5 (CNA 5) was observed arranging Resident 54's bed with no issues observed with regard to the space while she is doing the task. The room observation showed the room had spaces for the beds, tables, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 96 of 97 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055157 (X3) DATE SURVEY COMPLETED 12/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIRGIL REHABILITATION AND SKILLED NURSING CENTER 975 N Virgil Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cabinets, and personal belongings, and there was sufficient space for provisions of necessary care and services and for the residents to move freely inside the room. During an interview with CNA 5 on December 27, 2017 at 10:02 a.m., CNA 5 stated she has adequate space while providing care to Resident 54. During an interview with Certified Nursing Assistant 6 (CNA 6) on December 27, 2017 at 10:04 a.m., CNA 6 reported having adequate space while providing care to Residents 99, 37 and 49. A review of the waiver letter submitted by the Administrator on December 20, 2017, indicated the room measurements: Room # Beds Sq. Ft. per Resident 108 5 84.04 218 5 81.0264 219 5 81.0264 312 5 88.0 Sq. Ft. 420.2 405.132 405.132 440.0 A review of the Client Accommodation Analysis form dated December 8, 2017, indicated Rooms 108, 218, 219 and 312 have approved capacities of five (5) residents each room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X27C11 Facility ID: CA970000103 If continuation sheet 97 of 97