Virgil Rehabilitation & Skilled Nursing Center

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the care, assistance, and supervision to ensure an environment free of risks and hazards for one out of three sampled residents (Resident 1), by failing to ensure Resident 1 who required moderate assistance from facility staff with both upper and lower body dressing was not left alone undressed in the Resident's room after a shower on 6/22/2026. This failure resulted in Resident 1 falling on 6/22/2026 sustaining left hip redness, and left elbow skin excoriation (scraping or wearing away the skin) and placing the resident at risk for serious injury and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage, labeling, and/or disposal of medications and supplements in one of two inspected medication carts (Station 2 Medication Cart) and one of one inspected medication room (Station 2 Medication Room), according to manufacturer's specifications and the facility's policy and procedures (P&P), titled Storage of Medications, dated 1/20/2025, Discontinued Medications, dated 1/20/2025 and Hazardous Drug Handling, dated 1/20/2025, by failing to: A. Ensure that three unopened latanoprost (a medication used to treat glaucoma [high eye pressure]) ophthalmic solution vials in Station 2 Medication Cart were stored in the refrigerator or labeled with an open date when they were removed from the refrigerator. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. One expired medium container of tomato sauce with use by date (the last day the manufacturer guarantees the food's peak quality, flavor, and nutrient value) of 1/29/26 was stored in the facility's walk-in refrigerator. 2. One package of beef patty was stored in the facility's walk-in refrigerator to thaw with no date (indicates when a frozen food item was moved to the refrigerator to thaw). 3. The blade of the can opener located in the facility's food preparation area was worn and dented and had dried and sticky brown residue on it. 4. Apple sauce was stored at room temperature on two of two sampled medication carts in Nurses' station 2 (medication cart 1and 2) for longer than 4 hours. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner, when two of two trash bins were overfilled with the lids open. This deficient practice had the potential for harborage (accumulation of garbage, waste, debris, or materials that provide shelter, protection, food, or a breeding ground for pests such as rodents [rats, mice], insects, and other vermin) and feeding of pests and/or animals.

Inspectors wroteBased on interview and record review, the facility failed to inform one of five sampled residents (Resident 54) in advance of the risks and benefits of a psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior). This failure violated Resident 54's right to make an informed decision regarding the use of a psychoactive medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation to meet resident needs for three of three sampled residents (Residents 12, 53, and 74). By failing to:1. Ensure Resident 12 and Resident 74 were provided with a communication board (a bedside tool used to bridge gaps in verbal communication for residents who speak another language or have limited speech. These boards feature pictures, letters, or words representing basic needs, pain levels, and feelings, allowing residents to point to express themselves) in the language that Resident 12 and Resident 74 were able to understand.2. Provide Resident 53 who had limited use of hands with an appropriate call light (a device with a button or touchpad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 11's) medical information was kept private from unintended public view. This deficient practice had the potential to result in a breach of Resident 11's privacy and confidentiality.

Inspectors wroteBased on interview and record review, the facility failed to ensure to obtain an informed consent (voluntary agreement to accept treatment and/or procedure after receiving education regarding the risks, benefits, and alternatives offered) for the use of antipsychotic medication (medication used to treat the symptoms of schizophrenia, a mental illness that is characterized by disturbances in thought) from a resident who did not have the capacity to make healthcare decisions (the ability to use and understand information to make a decision and communicate any decision made) for one of five sampled residents (Resident 8). [...]

Inspectors wroteBased on interview and record review the facility failed to report an injury of unknown origin to the State Survey Agency (SSA, the Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Health, which is responsible for nursing facility certification and for conducting surveys to determine compliance with Medicare and Medicaid requirements) and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) within 2 hours when one of eight sampled residents (Resident 62) developed an acute fracture of the left distal fibula (broken left ankle bone). This failure had the potential to result in a delay of the onsite inspection by the SSA and had the potential for Resident 62's to suffer more injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to follow safe hazardous (dangerous) medication/drug handling procedures before the preparation and administration of medications that required to be administered with caution for one of six sampled residents (Resident 4) by failing to: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation for one of four sampled residents (Resident 14) with ROM limitations, after identifying a decline in range of motion (ROM, full movement potential of a joint) on 5/14/2025, to obtain a baseline measurement, adjust the splint to the right knee, set a goal for the splint wear tolerance (amount of time a person could wear a splint before experiencing discomfort or skin irritation), monitor the skin, and train the RNA on applying the splint establish goals for the splint. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to cap (cover) the enteral feeding (a way to deliver liquid nutrition directly into the stomach or small intestine through a soft, flexible tube) tube for one of two sampled residents (Resident 14) reviewed for enteral feeding. This failure had the potential for Resident 14's enteral tube feeding to become contaminated (the presence of unwanted or harmful substances that make something impure, unsafe, or unsuitable for its intended use, often by making it dirty) and increased the risk of infection.

Inspectors wroteBased on interviews, and record reviews, the facility failed to: 1. Clarify one of six sampled residents (Resident 31's) physician order for famotidine (a medication used to reduce the amount of acid produced by the stomach) dated 12/24/2025, which did not indicate a frequency (number of times) for taking the medication. 2. Ensure one of six sampled residents (Resident 80's) lidocaine patch (a medication in the form of a patch used to treat inflammation and pain) was available in stock at the facility. These deficient practices had the potential to cause medication errors for Resident 31 and inadequate pain relief for Resident 80 and placed both residents at risk for adverse health consequences such as acid-reflux, and decline in resident's mental, physical, functional or psychosocial status due to inadequate pain management.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control measures necessary to prevent the spread of infections by failing to ensure the staff wore full personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), including use of a face mask to cover both nose and mouth, during influenza ([flu] illness that infect the nose, throat, and lungs, causing sudden fever, cough, sore throat, body aches, and fatigue) season in accordance with the facility's policy and procedures titled Respiratory Virus Prevention and Control Plan, updated on 11/21/2025. These deficient practices had the potential to result in the spread of disease and illness throughout the facility, which could result in severe respiratory illness, hospitalization and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of 38 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) met the requirement of no more than four beds per room. This failure had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents who resided in room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER].

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of four sampled residents (Resident 1 and 2) who were fall risk, were provided with ordered and care-planned safety devices to reduce the risk of accidents. For Resident 1, the facility failed to ensure Resident 1's 's wheelchair had footrests and alarm as ordered by physician, and for Resident 2, the facility failed to ensure Resident 2 had footrests applied as recommended by Physical Therapy. These deficient practices had the potential to result in injury for Resident 1 and 2, during wheelchair transfer by facility staff.1. [...]

Inspectors wroteBased on interview and record review the facility failed to report the elopement (when a resident leaves/escapes from a facility without a physician's order and without the staff knowing) from the facility of one out of three sampled residents (Resident 1) to the California Department of Public Health (CDPH), Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement no later than 2 hours after Resident 1 went out on pass on 10/7/2025 at 12:50 PM and did not return to the facility, as per the facility's policy and procedures (P&P) titled Elopement, dated 1/2025. This failure resulted in the facility waiting until 10/8/2025 at 3 PM to notify CDPH, local law enforcement, and the Ombudsman, delaying the onsite inspection and investigation. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident's needs for one of three sampled residents (Resident 1). By failing to create and initiate a care plan for Resident 1's out on pass (temporary leave for a non-medical reason, such as a family visit or holiday meal) physician's order as indicated in the facility's Policy and Procedures (P&P) titled Out on Pass Policy and Procedures, dated 4/2024 and the facility's P&P titled Care Plans - Comprehensive, dated 1/2025 . [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one out of three sampled residents (Resident 1), who required supervision with walking, was assessed as risk for elopement (when a resident leaves/escapes from a facility without a physician's order and without the staff knowing), and was under Hospice (compassionate care for people who are near the end of life) care, did not leave the facility unsupervised while out on pass (temporary leave for a non-medical reason, such as a family visit or holiday meal) on 10/7/2025 at 12:50 PM. By failing to: 1. [...]

Inspectors wroteBased on interview and record review the facility failed to follow its policy and procedures (P&P), titled Out on Pass Policy and Procedure dated 4/2024 and P&P titled Physician orders and Telephone Orders with a review date of 1/2025, for one of three sampled residents (Resident 1) allowed to go out on pass (temporary leave for a non-medical reason, such as a family visit or holiday meal). By failing to ensure: 1. Resident 1's physician completed a medical evaluation of a resident's condition and reviewed the appropriateness of the resident's ability to safely leave the facility unsupervised and without direct access to facility staff. This failure resulted in Resident 1 leaving the facility unsupervised on 10/7/2025 at 12:50 PM and eloping (aka elopement: a patient or resident leaving a healthcare facility without permission and without being properly discharged ) from the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 1) who was confused, had a diagnosis of dementia (a progressive state of decline in mental abilities), and had a history of falls, did not elope (the act of leaving a facility unsupervised and without prior authorization) the facility on 8/20/2025 at approximately 3:45 AM by failing to: -Ensure Registered Nurse 1 (RN1) and other licensed nurses (in general) identified and assessed Resident 1 as a high risk for elopement. -Ensure RN2, Licensed Vocational Nurse3 (LVN3), and LVN2 supervised Resident 1 when Resident 1 tried to leave the facility on 8/20/2025 at 3:20 AM. -Ensure RN supervisors (in general) ensured the facility's door alarms were enabled (on) as indicated in the facility's Audible (able to be heard) Battery-Operated Door Alarm policy and procedure (P&P). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for two of five samples Residents (Residents 1 and 4) in accordance with professional standards of practice in order to meet resident's physical, mental, and psychosocial needs by failing to:1. Notify the physician about ineffective treatments for a generalized body rash as indicated in the Resident 1 care plan titled, alteration in skin as manifested by generalized body rash, initiated 7/29/2025.2. Implement a care plan for a rash on the left inner thigh for Resident 4 to monitor for effectiveness of the treatment. These deficient practices resulted in significant physical and psychosocial distress for both residents (Residents 1 and 4), including intense itching, insomnia, anxiety, depression, and reduced participation in daily activities. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was closely monitored (constant observation) to prevent a fall (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not because of an overwhelming external force). The facility was aware that Resident 1 was confused (is the inability to think as clearly or quickly as you normally do), legally blind (severe vision loss), at high risk for falls, at risk for elopement (leaving a facility unsupervised and unnoticed), restless (feeling uneasy, agitated, or unable to relax or stay still), and was unable to sit still. As a result, Resident 1 had a fall witnessed by Resident 2 (unidentified date and time) that resulted for Resident 1 to sustain a left hip fracture (broken bone). [...]

Inspectors wroteBased on interview and record review the facility failed for one of three sampled residents (Resident 1), to inform about Medicare co pay upon admission. This deficient practice caused the Resident 1's representative (RR) to be surprised by a bill and violated their right to be informed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident 21) had proper documented representation to make medical decisions, as there was no conservatorship application when Resident 21 was deemed non competent. This deficient practice caused an increased risk in the resident receiving care without proper documented representation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans for one of six sampled residents (Resident 35 and Resident 6). For Resident 35, who had a urinary tract infection (UTI-an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney), there was no care plan developed with individualized approaches. For Resident 6, the renal insufficiency care plan was not reviewed quarterly and the intervention was not implemented. These deficient practices had the potential to result in a delay or lack of delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the oxygen care plan for two of five sampled residents (Resident 35 and Resident 38), was reviewed and revised quarterly to reflect the resident's current status and interventions being provided to the resident. This deficient practice placed both residents at risk of unrecognized change of condition or delay in necessary intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 69) received proper oral care. The failure had the potential for Resident 69 to experience bad breath, infection, and lack of eating.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 35) received two liters of oxygen continuously, per the physician's order. This deficient practice had the potential to result in respiratory distress (difficulty breathing) for Resident 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: -Ensure carvedilol (a medication used to treat high blood pressure) bubble pack (a medication card containing tablets or capsules provided by pharmacy to the facility) hold parameters (parameters instructed by physician to follow to administer or not to administer high blood pressure medication to resident based on blood pressure reading) for blood pressure matched accurately with the hold parameters for blood pressure in facility's physician order, affecting one of four sampled residents (Resident 36) during medication pass observation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for one of four sampled residents (Resident 8). Resident 8 was not administered metformin (a medication used to treat Diabetes Mellitus [DM - a disorder characterized by difficulty in blood sugar control and poor wound healing]) within one hour of the prescribed time and was not provided Visine-A solution ([generic name - naphazoline-pheniramine eye drops], a medication used to treat irritation and dry eyes) in accordance with the physician's orders. These deficient practices caused a medication administration error rate of 6.67%, exceeding the five (5) percent threshold.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure storage and/or labeling of Resident 19's lorazepam (a controlled substance [a medication with a high potential for abuse] used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) 2 milligrams (mg - a unit of measurement for mass) per milliliters (mL - a unit of measurement for volume) concentrate per manufacturer's requirements in one of two inspected medication carts (Station 3 Medication Cart). This deficient practice had the potential to result in Resident 19 receiving lorazepam that had become expired, ineffective, or toxic due to improper storage and labeling possibly leading to anxiety and/or hospitalization due to health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices for one of four sampled residents (Resident 8) by failing to ensure sanitary environment in resident care areas. Resident 8's male urinal was full of urine and stored on the bedside cart along with other resident's belongings. This deficient practice had the potential to result in transmission of infectious microorganisms and increase the risk of infection for Resident 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure rooms meet the requirement of no more than 4 beds per room for four sampled resident rooms (room [ROOM NUMBER], 218, 219, and 312). This deficient practice had the potential to affect the delivery of care and safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for two of the two sampled residents (Resident 12, 39). This deficient practice had the potential to result in the residents not being able to summon a health care worker for help as needed.

Inspectors wroteBased on interview, the facility failed to ensure mail was delivered to residents on Saturdays. This had the potential to affect all residents in the facility who received personal mail, including but not limited to 4 of 11 residents (Resident 3, Resident 4, Resident 6, Resident 10) at the resident council meeting, who verbally confirmed not receiving mail on Saturdays.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents clinical records contained an advance directive (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) acknowledgement form for three out of the three sampled residents (Resident 12, 57, 269). This deficient practice had the potential to cause conflict with a resident's wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain residents' room temperature level between 71- and 81-degree Fahrenheit (° F) as required by the Federal regulation for one of three sampled residents (Resident 1) and three of five rooms checked during an environmental tour. This deficient practice resulted in the resident's increased level of discomfort and had the potential to negatively impact the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for three of five sampled residents (Resident 45, 65 and Resident 269) by failing to ensure the residents oxygen tubing and humidification bottles were dated per the facility's Oxygen Administration - Resident, policy and procedure. This deficient practice had the potential to result in complications associated with oxygen therapy, including infection or respiratory distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staffing information was posted and placed in a visible and prominent place daily. As a result, the total number of staff and the actual hours worked by the staff were not readily accessible to residents and visitors.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Store food in accordance with professional standards for food service safety by failing to: a. Label four gallons of Salad oil with the receiving date. b. Label ten containers of grits with the receiving date. c. Label two cans of apple juice with the receiving date. 2. Discard open canned mushrooms after three days of storage in the refrigerator. These deficient practices had the potential to result in food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for two of the two sample residents (Residents 56 and 57) by failing to ensure the residents' urinals (a container used to collect urine) were labeled with residents' names and room numbers. This deficient practice had the potential to result in the contamination of the residents' care equipment and placed the residents at risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of 38 residents rooms, room [ROOM NUMBER], 218 and 219 accommodated no more than four residents per room. The three rooms each had 5 residents in the rooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the resident.

Inspectors wroteBased on interview, and record review, the facility failed to provide a bed hold notification (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) at the time of transfer to the hospital for one of three sampled residents (Resident 19). This deficient practice denied Resident 19 or her Responsible Party (RP) of being informed of her right to have the facility hold and reserve her bed while absent from the facility.

Inspectors wroteBased on interview, and record review, the facility failed to develop an individualized person-centered care plan to meet the resident's need for one of five sampled residents (Resident 37) by failing to develop a care plan with goals and interventions for colostomy (creating a hole in the abdominal wall allows waste to leave the body) care. This deficient practice had the potential to result in inadequate care of Resident 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy titled Smoking Policy - Residents, for one of four sampled residents (Resident 43). This deficient practice placed Resident 43 at increased risk for injuries related to smoking.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure discontinued medication was not available in the medication cart for use for one (1) of 39 sampled residents (Resident 14), There was a package of 25 tablets of hydrocodone/APAP (Norco, a potent narcotic and controlled substance to treat pain) 10/325 milligrams (mg, a unit to measure weight) in Medication Cart 1. The controlled drug record indicated Resident 14 received 1 dose of Norco on 12/24/23 around 1:30 PM. However, the Norco medication order had been discontinued on 12/21/23. Additonally, the nurse who administered the Norco dose had incorrectly documented the administration as Norco 5/325 mg (which was the active order at the time). This deficient practice had the potential to result in drug diversion and/or medication errors. (cross referrece to F760)

Inspectors wroteBased on interview and record review, the facility failed to ensure there was documentation of the specific behavior exhibited when an antipsychotic (medication that alter brain chemistry to help reduce psychotic symptoms such as hallucination, delusion, and disordered thinking) was administered, as needed, to one (1) of 39 sampled Resident (65). This deficient practice had the potential to result in administering unnecessary medication, and/or a medication error.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of 39 sampled residents were free from significant medication errors (an error in medication administration that may jeopardizes a resident's health and/or safety), as evident by failing to administer the correct dose of hydrocodone/APAP (Norco, a potent narcotic and controlled substance to treat pain) as per order, for Resident 14. (Cross reference to F755)