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The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Virgil Rehabilitation & Skilled Nursing Center during CMS and state inspections, most recent first.
Two residents with dementia, weakness, and impaired mobility who required maximal assistance for transfers and locomotion were observed seated in wheelchairs without footrests, despite one having PT-indicated need for footrests and the other having orders for a wheelchair alarm and a floor mat. Staff interviews confirmed that the wheelchair for one resident lacked footrests and an alarm and that no floor mat was present, while the activity assistant reported not being trained in wheelchair transfers or aware of why footrests were missing. Nursing and therapy staff acknowledged that residents with weakness or fall risk should have footrests and that ordered alarms and floor mats must be implemented, yet these interventions were not in place as required by the facility’s fall management policy.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report highlights insufficient safety measures and lack of proper oversight, but does not specify individual residents or staff actions.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and supervision was insufficient to prevent incidents.
A resident's representative was not informed of a Medicare co-pay upon admission, resulting in a surprise bill. The resident, with cognitive impairments and requiring maximal assistance, was admitted with 21 days of Medicare coverage left. The business office manager failed to communicate the co-pay, and the representative only learned of it after receiving a bill post-transfer.
A facility failed to ensure a resident with epilepsy, Parkinson's disease, and dementia had proper representation for medical decisions after being deemed non-competent. Despite the resident's deteriorating condition and multiple hospitalizations, no conservatorship application was submitted, and the facility relied on two physician signatures on the POLST, contrary to policy. The Director of Nursing acknowledged the need for a conservatorship application.
The facility failed to develop and update comprehensive care plans for two residents, one with a UTI and another with chronic kidney disease on dialysis. The first resident did not have a care plan after being prescribed an antibiotic for a UTI, while the second resident's care plan was not reviewed quarterly, and daily weight monitoring was not implemented. These deficiencies were acknowledged by the facility's staff, including the DON, and were contrary to the facility's policies.
The facility failed to update care plans quarterly for two residents, one with respiratory failure and another with communication issues due to a traumatic brain injury. The care plans were not revised to reflect current interventions, despite the facility's policy requiring quarterly updates and changes in condition. Staff interviews highlighted the potential harm of improper care and communication issues without updated care plans.
A resident with reduced mobility and muscle weakness did not receive proper oral care, as evidenced by a creamy substance on their teeth. Despite the resident's refusal of assistance being noted once, the oral care task spreadsheet inaccurately indicated that care was provided. Staff interviews revealed a lack of proper documentation and reporting of refusals, contrary to facility policy.
A resident with respiratory failure was not receiving continuous oxygen therapy as prescribed, as the oxygen concentrator was found turned off during an observation. The resident had to manually turn it on to receive the prescribed two liters per minute. The LVN and DON confirmed that the concentrator should be checked every shift to ensure proper function, and the failure to do so put the resident at risk for respiratory distress.
The facility failed to ensure accurate medication administration and availability for two residents. A resident's carvedilol bubble pack did not match the physician's hold parameters, risking medication errors. Another resident received metformin late, risking hyperglycemia, and lacked Visine eye drops for eye irritation. The DON confirmed these deficiencies.
A resident with Type II Diabetes Mellitus was not administered metformin within the prescribed time, resulting in a medication error rate of 6.67%. Additionally, Visine-A eye drops were not available when needed for the resident's eye irritation. The facility's policy requires medications to be administered within one hour of their prescribed time, and PRN medications should be available when needed.
A facility failed to properly store and label lorazepam for a resident with anxiety disorder. The medication was found in a medication cart without an opened date label and was not stored in a refrigerator as required by the manufacturer's specifications. The LVN confirmed the medication was not safe to administer due to improper storage, and the DON acknowledged that the medication would not be effective or safe for the resident's treatment.
A facility failed to maintain infection control practices for a resident by allowing a full urinal to be stored on a bedside table with personal items, posing a risk of infection. The resident, with Type II Diabetes Mellitus, required assistance for daily activities. Staff acknowledged the oversight, and the facility's infection control policies were not followed.
The facility did not comply with the requirement that resident rooms hold no more than four residents, as observed in four rooms. A resident and a CNA confirmed adequate space for privacy and care activities, including using a Hoyer lift. However, the facility's policy requires a waiver for rooms exceeding four residents, and a waiver was approved for these rooms, suggesting a potential oversight in policy compliance.
Failure to Provide Ordered Wheelchair Safety Devices and Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents at risk for falls were provided with ordered and care-planned safety devices, specifically wheelchair footrests, a wheelchair alarm, and a floor mat. Resident 1 was admitted with diagnoses including degeneration of the brain, dementia, weakness, and bilateral knee osteoarthritis, and had an MDS showing severely impaired cognition and a need for maximal assistance with most ADLs and locomotion on and off the unit. Resident 1’s orders included use of a wheelchair alarm when up in the wheelchair to alert staff if attempting to get up unassisted, and a floor mat on the right side of the bed to prevent injury from any fall. Despite these orders, observation and staff interview revealed that Resident 1’s wheelchair did not have footrests or a wheelchair alarm, and there was no floor mat in the room. Resident 2 was admitted with weakness, osteoporosis, and Alzheimer’s disease, and also had an MDS indicating severely impaired cognition and a need for maximal assistance with transfers, including sit-to-stand and chair/bed transfers, and supervision or partial assistance with other ADLs. The comprehensive care plan indicated a need for maximal assistance with locomotion on and off the unit. Physical therapy staff indicated that Resident 2 should have a footrest due to recent hospitalization, current weakness, and ongoing therapy three times a week. However, during observation in the activity room, Resident 2 was seated in a wheelchair without footrests. During the same observation in the activity room, both Resident 1 and Resident 2 were seen sitting in wheelchairs without footrests. The activity assistant present stated he had not been trained in transferring residents in wheelchairs and did not know why the residents did not have footrests. A CNA confirmed that Resident 1’s wheelchair lacked footrests and an alarm, and that there was no floor mat in the room, and began searching for the footrests. The QA nurse and MDS nurse both stated that residents with weakness, hemiplegia, or fall risk should have footrests, and that ordered alarms and floor mats should be implemented to ensure safety. The facility’s fall management policy stated that staff, in conjunction with the attending physician, will identify and implement appropriate interventions to reduce fall risk and minimize serious consequences of falling, but the ordered and recommended safety devices were not in place for these residents.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific actions or omissions by staff or management that led to this deficiency are not detailed in the report, nor are any particular residents or their medical histories mentioned.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents, and that supervision measures were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Inform Resident's Representative of Medicare Co-Pay
Penalty
Summary
The facility failed to inform a resident's representative about the Medicare co-pay upon admission, leading to a surprise bill. The resident was admitted with diagnoses including pneumonia, adult failure to thrive, dementia, and anxiety. The Minimum Data Set indicated the resident's cognition was not intact, and they required maximal assistance with daily activities. Upon admission, the business office manager ran a Medicare eligibility report, which showed the resident had 21 days of coverage left with a co-pay of $209.50 per day. However, this information was not communicated to the resident's representative. The resident's representative attended an interdisciplinary team meeting via phone, where the social services assistant believed the resident's stay was completely covered. The business office manager was not part of this meeting and did not inform the representative of the co-pay. The representative only learned of the co-pay after receiving a bill in the mail following the resident's transfer to another facility. The facility's policy requires reviewing financial obligations with residents or their representatives upon admission, which was not adhered to in this case.
Failure to Ensure Proper Representation for Non-Competent Resident
Penalty
Summary
The facility failed to ensure that a resident, who was deemed non-competent, had proper documented representation to make medical decisions. The resident, who had diagnoses including epilepsy, Parkinson's disease, and dementia, was admitted without a conservatorship application despite being unable to understand and make decisions. A review of the resident's records showed that a public guardian was initially assigned to investigate the need for conservatorship in 2015, but no petition was filed due to a lack of imminent need. However, by 2020, the resident's condition had deteriorated, and they were unable to make decisions, yet no new application for conservatorship was submitted. Interviews with facility staff revealed that the resident had been hospitalized multiple times in 2024 and returned to the facility in a nonverbal and nonresponsive state. Despite this, the facility relied on two physician signatures on the resident's POLST to make decisions, which was not in line with the facility's policy for representation. The Director of Nursing acknowledged that a conservatorship should have been applied for when the resident was deemed non-competent. The facility's policy indicated that legal authority for health care decisions should include a court-appointed legal guardian or conservator, which was not in place for this resident.
Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to potential delays or lack of care. For one resident with a urinary tract infection (UTI), the facility did not create a care plan after the resident was prescribed Macrobid, an antibiotic for UTI, following a change in condition. The Quality Assurance nurse and the Director of Nursing both acknowledged that a new care plan should have been initiated when there was a change of condition or a new medication order. The facility's policy required care plans to be revised as changes in the resident's condition dictate and reviewed at least quarterly. Another resident with chronic kidney disease and on renal dialysis had a care plan that was not reviewed quarterly, and the intervention to monitor daily weight gain was not implemented. The Registered Nurse Supervisor noted that the facility only had monthly and post-dialysis weights, not daily weights as required by the care plan. The Director of Nursing confirmed that the care plan was last revised over a year ago and should have been updated. The facility's policy indicated that care plans should be reviewed quarterly to enhance resident function and prevent declines.
Failure to Update Care Plans Quarterly for Two Residents
Penalty
Summary
The facility failed to ensure that the oxygen care plans for two residents, Resident 35 and Resident 38, were reviewed and revised quarterly to reflect their current status and interventions. Resident 35 was admitted with diagnoses including respiratory failure, acidosis, and heart failure. The care plan for Resident 35, revised on December 1, 2023, included interventions such as elevating the head of the bed and providing oxygen as ordered. However, the care plan was not updated quarterly as required, despite the resident being on continuous oxygen therapy. The Director of Nursing acknowledged the importance of updating care plans to facilitate resident-centered care. Resident 38, admitted with a history of traumatic brain injury and acquired deformity of the head, had a care plan related to communication problems last revised in April 2021. Observations indicated that Resident 38 communicated using a Spanish communication board and required assistance from a CNA for interpretation. The Quality Assurance Nurse noted that the care plan had been revised in December 2024, but the revision date was not reflected in the care plan. The Information Technologist explained that the revision date would only change with a doctor's order or a change in condition. Interviews with facility staff, including the MDS Nurse and the Registered Nurse/Nursing Supervisor, highlighted the potential harm to residents without updated care plans, such as improper care and communication issues. The Director of Nursing reiterated the policy that care plans should be revised quarterly, as needed, and when there is a change in condition. The facility's policy emphasized the need for the Interdisciplinary Team to review and update care plans in response to changes in condition, unmet desired outcomes, readmissions, and quarterly assessments.
Failure to Provide Proper Oral Care
Penalty
Summary
The facility failed to ensure proper oral care for Resident 69, who was admitted with diagnoses including reduced mobility, muscle weakness, and age-related physical debility. The resident was alert and oriented, requiring substantial assistance with oral hygiene. During observations, a creamy substance was noted on the resident's teeth, indicating inadequate oral care. Despite the resident's refusal of assistance on one occasion, the oral care task spreadsheet indicated that oral care was performed, but the refusal was not properly documented. Interviews with staff revealed inconsistencies in the documentation and reporting of oral care refusals. CNA 2 acknowledged that the resident refused oral care once, but this was not accurately reflected in the records. LVN 1 and the DON confirmed that refusals should be documented and reported, but this was not done. The facility's policy required documentation of mouth care and notification of supervisors in case of refusal, which was not adhered to, leading to the deficiency.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident received continuous oxygen therapy as prescribed by the physician. The resident, who was admitted with diagnoses including respiratory failure with hypoxia, acidosis, and heart failure, was supposed to receive two liters of oxygen per minute via nasal cannula continuously. However, during an observation, it was noted that the oxygen concentrator was not turned on, and the resident had to manually activate it to receive the prescribed oxygen flow. Interviews with the LVN and the DON revealed that the oxygen concentrator should be checked at the beginning of every shift to ensure it is functioning properly. The LVN acknowledged that the resident could become hypoxic if the oxygen was not administered continuously. The DON confirmed that the LVN was responsible for checking the oxygen concentrators and that the failure to provide oxygen as ordered put the resident at risk for respiratory distress.
Medication Administration and Availability Deficiencies
Penalty
Summary
The facility failed to ensure that the carvedilol medication bubble pack for a resident matched the physician's hold parameters for blood pressure. The physician's order indicated that the medication should be held if the systolic blood pressure (SBP) was less than 100 and the heart rate (HR) was less than 60. However, the medication bubble pack indicated hold parameters of SBP less than 110 or HR less than 60. This discrepancy was observed during a medication pass, and the Licensed Vocational Nurse (LVN) acknowledged the mismatch, which could lead to medication errors and blood pressure abnormalities. Another deficiency involved the administration of metformin for a resident with Type II Diabetes Mellitus. The facility's policy required medications to be administered within one hour of the prescribed time. However, the metformin was administered almost an hour late, increasing the risk of hyperglycemia. The Registered Nurse (RN) admitted to the delay and acknowledged the potential risk of hospitalization due to the late administration. Additionally, the facility failed to have Visine eye drops available for a resident who complained of eye irritation. Although the medication was prescribed as needed, it was not available when the resident requested it, leading to potential worsening of eye discomfort. The Director of Nursing (DON) confirmed that the medication should have been available, and the lack of availability could result in eye irritation and redness.
Medication Administration Errors Exceeding 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during a medication pass for a resident, resulting in a medication administration error rate of 6.67%. The resident, who was diagnosed with Type II Diabetes Mellitus, was not administered metformin within one hour of the prescribed time. The medication was scheduled for administration at 7:30 AM but was documented as administered at 9:23 AM, almost one hour late. This delay was acknowledged by the Registered Nurse/Nursing Supervisor (RNS) 1, who admitted the mistake and recognized the risk of hyperglycemia and potential hospitalization for the resident due to the late administration. Additionally, the resident was not provided with Visine-A eye drops as needed for eye irritation and discomfort, as the medication was not available when requested. The RNS 1 admitted to not having the Visine eye drops available, despite it being a PRN medication, and acknowledged the risk of worsening eye discomfort for the resident. The Director of Nursing confirmed that the facility's policy required medications to be administered within one hour of their prescribed time and that PRN medications should be available for administration when needed.
Improper Storage and Labeling of Lorazepam
Penalty
Summary
The facility failed to ensure proper storage and labeling of lorazepam, a controlled substance, for Resident 19. During an inspection of the Station 3 Medication Cart, it was observed that Resident 19's lorazepam oral concentrate was not labeled with an opened date, which is required by the manufacturer's specifications. The medication was also not stored in a refrigerator as required, which could compromise its effectiveness and safety. The Licensed Vocational Nurse (LVN) confirmed that the medication should have been labeled with an open date and stored in a refrigerator, and acknowledged that the medication was not safe to administer due to improper storage. Resident 19, who was admitted with diagnoses including palliative care and anxiety disorder, was dependent on facility staff for daily living activities and had severely impaired cognition. The Physician's Order Summary Report indicated that lorazepam was prescribed to be administered sublingually as needed for anxiety. However, the absence of proper labeling and storage meant that the medication's expiration could not be determined, potentially affecting the resident's treatment for anxiety and agitation. The Director of Nursing (DON) confirmed that the medication would not be effective or safe to administer under these conditions.
Infection Control Lapse with Resident's Urinal
Penalty
Summary
The facility failed to maintain proper infection control practices for one of the residents, identified as Resident 8, by not ensuring a sanitary environment in the resident's care area. During an observation, a male urinal containing urine was found on the bedside table alongside other personal items such as a drinking water container, a water bottle, and a mobile phone. This situation was noted during a medication administration by a Registered Nurse/Nursing Supervisor (RNS) who acknowledged that the urinal should have been emptied and not stored with other belongings, as it posed a risk for infection and cross-contamination. Resident 8, who was originally admitted in 2009 and readmitted later, had diagnoses including Type II Diabetes Mellitus and required varying levels of assistance for daily activities. The Director of Nursing (DON) confirmed that the Certified Nurse Assistant, housekeeping, and Licensed Vocational Nurse should have ensured the cleanliness and sanitation of Resident 8's care areas. The facility's policies on infection control and standard precautions were reviewed, indicating that all bodily fluids should be managed to prevent infection, but these were not adhered to in this instance.
Non-Compliance with Resident Room Capacity Requirements
Penalty
Summary
The facility failed to comply with the requirement that resident rooms hold no more than four residents, as observed in four sampled rooms. During an observation and interview, a resident in a room with four beds expressed satisfaction with the space available for privacy and family visits. A CNA assigned to the room confirmed there was sufficient space to perform duties, including using a Hoyer lift for a resident. Despite these observations, a review of the facility's policy indicated that rooms should not exceed four residents, and any room not meeting this requirement would need a waiver from CDPH. A waiver request letter dated earlier in the year showed approval for rooms with more than four beds, indicating a potential oversight in ensuring compliance with the room size policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hollywood Presbyterian Medical Center D/p Snf | 0.4 mi | — | 22 | 0 |
| Garden Crest Rehabilitation Center | 0.7 mi | — | 15 | 0 |
| The Meadows On Sunset Post Acute | 0.8 mi | — | 49 | 1 |
| Alexandria Care Center | 0.9 mi | — | 14 | 0 |
| Palazzo Post Acute | 1.2 mi | — | 4 | 0 |
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