Other·December 31, 2019

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 reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint Number: CA00658805 Representing the California Department of Public Health: Health Facilities Evaluator Nurse: 39664 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. A deficiency was issued for Complaint Number: CA00658805.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 12/13/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in 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: 0VD211 Facility ID: CA970000103 If continuation sheet 1 of 4 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 12/10/2019 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 State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report to the state agency (Department of Public Health) an injury of unknown origin that resulted in a fracture (broken bone) of the fourth proximal phalanx (ring finger) for one of three sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' injury of unknown origin was investigated and could lead to a delay in prevention of further injuries to other residents. Findings: A review of the Admission Record indicated Resident 1 was originally admitted to the facility, on 7/22/18 and readmitted on 10/14/19, with diagnoses including pressure ulcer of sacral region (injury to the skin on the tailbone due to prolong pressure). A review of the Minimum Data Set (MDS- a standardized assessment and screening tool), dated 9/6/19, indicated Resident 1 had severely impaired cognitive skills (mental process of thinking and understanding) for daily decision making. The MDS indicated Resident 1 was totally dependent and needs two-person FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VD211 Facility ID: CA970000103 If continuation sheet 2 of 4 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 12/10/2019 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 physical assistance with transfers (how a resident moves between surfaces such as a bed, chair, wheelchair) and bed mobility (how a resident moves to and from lying positions, turns side to side, and positions body while in bed). A review of Resident 1's x-ray of the left hand, dated 10/1/19, indicated there was an acute (recent) fracture at the base (bottom) of the fourth proximal phalanx (the bones that are found at the bottom of the finger). A review of the fax from State Agency 2, dated 10/11/19, indicated Stage Agency 1 was informed of an allegation of possible neglect of Resident 1. During an interview, on 12/9/19 at 9:33 a.m., Licensed Vocational Nurse 1 stated that Resident 1 was transferred out to the General Acute Care Facility (GACH), on 10/2/19, due to a fracture of the finger. LVN 1 stated that prior to the transfer, he had noted swelling on Resident 1's arm, and informed the physician, who ordered for X-ray (imaging to view the bone and other body structures). LVN 1 stated that it was discovered that the resident had sustained a fracture and was sent to the GACH for further evaluation. During an interview, on 12/9/19 at 1:07 p.m., the Director of Nursing (DON) stated and confirmed the fracture of Resident 1's fourth proximal phalanx on the left hand was an injury of unknown origin. When asked if it was reported to the proper state agencies, the DON stated they did not report the incident. During an interview, on 12/9/19 at 1:19 p.m., the Administrator stated and confirmed that the fracture of Resident 1's fourth proximal phalanx on the left hand was an injury of unknown FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VD211 Facility ID: CA970000103 If continuation sheet 3 of 4 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 12/10/2019 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 origin. When the Administrator was asked if injuries of unknown origins need to be reported to the proper state agencies, the Administrator stated that injuries of unknown origins do not always need to be reported. A review of the facility's policy and procedure titled, "Unusual Occurrence Reporting," undated, indicated that the facility reports, as required by federal or state regulations, unusual occurrences or other reportable events which affect the health, safety, or welfare of their residents, employees or visitors. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VD211 Facility ID: CA970000103 If continuation sheet 4 of 4