Virgil Rehabilitation & Skilled Nursing Center

In the surveyor’s words

From the most serious findings on record at Virgil Rehabilitation & Skilled Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 23, 2025

  Based 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. […]

• Actual harm, isolatedF689Jul 29, 2025

  Based 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. […]

• Actual harm, isolatedF689Feb 1, 2023

  Based on interview and record review the facility failed to provide a safe environment for one of three sampled residents (Resident 1). The facility failed to: -Develop and implement a person-centered comprehensive Elopement (when a patient who leaves the healthcare facility unnoticed and doing so may present an imminent threat to the patient's health or safety because the patient has been deemed too ill or impaired to make a reasoned decision to leave) care plan upon admission on 10/12/2022. -Ensure the door in Resident 1's room that led outside the facility had the alarm activated and in working condition. […]

• No harm, potential for more than minimal, patternF761Feb 6, 2026

  Based on observation, interview, and record review, the facility failed to ensure proper storage, labeling, and/or disposal of medications and supplements in one of two inspected medication carts (Station 2 Medication Cart) and one of one inspected medication room (Station 2 Medication Room), according to manufacturer's specifications and the facility's policy and procedures (P&P), titled Storage of Medications, dated 1/20/2025, Discontinued Medications, dated 1/20/2025 and Hazardous Drug Handling, dated 1/20/2025, by failing to: A. […]

• No harm, potential for more than minimal, patternF812Feb 6, 2026

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