Health inspection·March 17, 2023

F 0550 dining area which was full of residents. Level of Harm - Minimal harm or potential for actual harm On 3/14/2023, at 12:00 p.m., during an observation, the residents' dining room doors were closed, and the facility staff were observed eating lunch in the residents' dining room. Residents Affected - Some On 3/14/2023, at 1:00 p.m., during an interview, Resident 53 stated he would like to have the option to eat and watch TV (television) in the dining room. On 3/14/2023 at 1:30 p.m., during an interview, the Infection Preventionist Nurse (IPN-) stated the facility closed the communal (residents') dining because several residents had tested positive for Coronavirus disease (COVID-19-is an infectious [likely to be transmitted] disease caused by the SARS-CoV-2 virus). The IPN stated the facility has not had a resident in isolation (to separate) for about three weeks and was preparing a list of residents requesting to eat in the dining room. On 3/17/2023, at 7:45 a.m., during an observation, the residents' dining room doors were closed, and no residents were in the residents' dining room. Staff were observed serving several breakfast trays to residents in their rooms. On 3/17/2023, at 7:46 a.m., during an interview, the Administrator (ADMIN) stated, the residents can and should have the right to receive dining services. The ADMIN stated the last confirmed COVID positive case was on 2/9/2023 and the dining room should have been reopened for residents. On 3/17/2023, at 8:35 a.m., during an interview, Resident 30 stated he eats outside because the facility staff eat in the residents' dining room. A review of the facility's policy and procedures (P&P) titled Respect, Dignity/Right to have personal property, reviewed on 8/19/2022, indicated, it is the policy of the facility to provide care and services in such a manner to acknowledge and respect resident rights. Exercising rights means that residents have autonomy and choice, to maximize extent possible, about how they wish to live their everyday lives and receive care, subject to the facility rules, as long as those rules do not violate a regulatory requirement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 2 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure: Residents Affected - Few 1. Ensure the residents were educated on the facility's grievance process and provided the location to obtain grievance forms for seven of seven resident who attended the Resident Council Meeting, the resident were not aware of the facility's grievance process and did not know where to obtain a grievance forms. 2. Follow up on grievance for the lost upper dentures (artificial teeth) for one of two sampled residents (Resident 49). These deficient practices had the potential for a decline in quality of life and inability to file grievances for residents in the facility. Findings: 1. During a resident council meeting on 3/15/2023 at 1:30 p.m., seven resident council members shared the facility did not inform/educate them about the grievance forms and the grievance process. On 3/16/2023 at 9:30 a.m., during an interview, the Social Services Director (SSD) stated, the facility does have a grievance process as known as Concern Resolution Program. The SSD further stated the resident inform staff if the residents have a concern for any reason and the staff completes a concern record. The SSD stated the concern records are located at the front desk of the social services office and at the nursing stations. The SSD stated all staff educate the residents on admission about the grievance process. The SSD stated a grievance form is completed, submitted to the SSD office when a resident has a concern, and then forwarded to the correct department head for investigation and the concern is discussed with the resident. On 3/16/2023 at 10:15 a.m., during an observation, the SSD confirmed and stated there were no concern record forms located at Nursing Station 2 (Two). The SSD stated she would place a new binder with concern records in Nursing Station 2. A review of the facility's policy and procedures titled Concern Resolution Program dated 7/2013, indicated This facility will identify, investigate, and resolve concerns of residents/family members and others . The Administrator is the concern coordinator, The concern forms are available at the front desk, social service office and nursing stations for residents, responsible parties, and others to document their concerns. Concerns will be directed to the appropriate department head/responsible staff member for a follow up as indicated, this may require immediate follow up. 2. A review of Resident 49's admission Record indicated the facility initially admitted Resident 49 on 1/14/2021 and was readmitted on [DATE] with diagnoses including Alzheimer's Diseases (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and hypertension (high blood pressure). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 3 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 49's care plan titled alteration of oral dental status dated 1/21/2021, indicated Resident 49 wore full upper and full lower dentures. The care plan interventions indicated assess dental condition and refer to dentist as indicated. A review of Resident 49's oral/dental assessment dated [DATE] timed at 10:35 a.m., indicated staff referred to social services for dental consult for possible replacement of lost dentures for Resident 49. A review of Resident 49's concern record form (theft/loss and grievance report) dated 10/20/2021, indicated Resident 49's responsible representative reported Resident 49's dentures were missing. The care plan further indicated Resident 49's lower dentures were present. but upper dentures were not found. A review of Resident 49's Minimum Data Set (MDS- a standardized screening and assessment tool) dated 1/13/2023, indicated Resident 49 had limited ability to make herself understood by making simple requests and had limited ability to understand others by responding to simple, direct communication only. The MDS indicated Resident 49 did not have natural teeth or tooth fragments and was on a mechanically altered diet (modified diet that restricts foods that are difficult to chew or swallow). On 3/14/2023, at 8:23 a.m., during a concurrent observation and interview, Resident 49 was observed eating breakfast and was not wearing dentures (artificial teeth). Resident 49 stated (translated by the Social Services Director (SSD) she wanted dentures. On 3/14/2023, at 08:28 a.m., during an interview, the SSD verified and stated Resident 49's dentures were lost the dentures and was not sure when Resident 49 lost them. On 3/15/2023, at 3:12 p.m., during a concurrent interview and record review, Registered Nurse Supervisor (RNS) confirmed and stated Resident 49's care plan on alteration of oral dental status dated 1/21/2021, indicated Resident 49 had both her upper and lower dentures. On 3/16/2023, at 7:44 a.m., during an observation, Resident 49 was observed eating breakfast with no dentures. Translation provided by the SSD. Resident 49 stated she still wants dentures. On 3/16/2023, at 7:46 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated Resident 49 previously had dentures but were lost and was uncertain if Resident 49 still had the dentures or not. On 3/16/2023, at 1:23 p.m., during a concurrent interview and record review, the SSD stated she completed a concern record form for the dentures on 10/20/2021 and had notified Resident 49's family member about the lost dentures. The SSD confirmed and stated the concern record form indicated Resident 49's upper dentures were missing. The SSD further stated it was the facility responsibility to keep track and replace Resident 49's dentures if the insurance company did not cover the missing dentures. The SSD verified and stated there was no follow-up for the lost dentures for Resident 49. A review of the facility's policy and procedures (P&P) titled Dental Services, revised on 12/2016 and reviewed on 8/19/2022, indicated, Dentures will be protected from loss or damage to the extent practicable, while being stored. Lost or damaged dentures will be replaced at the resident's expense unless an employee or contractor of the facility is responsible for accidentally or intentionally damaging the dentures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 4 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedures P&P) titled (Grievances) Concerns Resolution Program, reviewed on 8/19/2022, indicated, to identify investigate and resolve concerns presented by residents, responsible parties, families, or staff members to improve customer service. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 5 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an interview and record review, the facility failed to immediately report and no later than two hours, two incidents of allegation of resident to resident abuse to the California Department of Public Health (CDPH), to ombudsman (advocates for the residents of long-term care facilities), and to local law enforcement, for one of three sampled residents (Residents 77) as evidenced by: 1. Resident 7 cursed and threw cups multiple times at Resident 77. 2. Resident 15 cursed and scratched Resident 77. 3. Resident 15 attempted to take Resident 77's computer. This deficient practice had the potential for delayed investigation and placed Resident 77 at increased risk for further abuse. Findings: A review of Resident 7's admission Record indicated the facility initially admitted Resident 7 on 8/11/2022 and readmitted Resident 7 on 2/17/2023 with diagnoses including schizophrenia (a serious mental disorder in which people interpret reality abnormally), psychosis (to perceive or interpret reality in a very different way from people), hypertension (high blood pressure), muscle weakness, mood disorder, anxiety disorder, insomnia (difficulty falling or staying asleep), and encephalopathy (any disease of the brain that alters brain function or structure), nicotine dependence (is an addiction to tobacco products caused by the drug nicotine), and alcohol abuse. A review of Resident 7's Minimum Data Set (MDS- a standardized screening and assessment tool) dated 2/24/2023, indicated Resident 7 was unable to make daily decisions or make himself understood. Resident 7 required limited one staff assist with transfers from bed and ADLs. A review of Resident 15's admission Record indicated the facility initially admitted Resident 15 on 6/21/2017 and readmitted Resident 15 on 2/13/2023 with diagnoses including psychosis, schizophrenia, bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and major depressive disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 15's MDS dated [DATE], indicated Resident 15 was unable to make daily decisions or make herself understood. Resident 15 required limited to extensive one staff assist with transfer from bed and for ADLs. A review of Resident 26's admission Record indicated the facility admitted Resident 26 on 7/06/2022 with diagnoses including schizoaffective disorder, anxiety disorder, and insomnia. A review of Resident 26's MDS dated [DATE], indicated Resident 26 had intact cognition. A review of Resident 77's admission Record indicated the facility initially admitted Resident 77 on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 6 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4/20/2022 and readmitted Resident 77 on 1/11/2023 with diagnoses including muscle weakness, difficulty walking, and anxiety disorder (involves persistent and excessive worry that interferes with daily activities). A review of Resident 77's MDS dated [DATE], indicated Resident 77 was cognitively (mental ability to make decisions of daily living) intact for making decisions regarding tasks of daily life and required assistance with transfers from bed and a staff person's physical assistance for activities of daily living (ADLs - bed mobility, transfers from bed, eating, dressing, toilet use, and personal hygiene). On 3/17/2023, at 8:23 a.m., during an interview, Resident 77 stated on multiple times, Resident 7 cursed her out, threatened her, and threw cups at her while she [Resident 7] was outside smoking. Resident 77 stated Resident 26 (roommate) always accompanied her and protected her from Resident 7 whenever she (Resident 77) went outside to smoke. Resident 77 stated she reported the incidents with Resident 7 to the Director of Nursing (DON), Licensed Vocational Nurse 1 (LVN 1), and the Social Services Director (SSD) on 1/6/2023 and 2/9/2023. On 3/17/2023, at 8:27 a.m., during an interview, Resident 26 stated she witnessed Resident 7 mess [curse at] with Resident 77. Resident 26 stated she always protected Resident 77 from Resident 7 whenever Resident 77 goes outside to smoke a cigarette. Resident 26 stated Resident 7 throws cups at Resident 77. On 3/17/2023, at 8:42 a.m., during an interview, Resident 77 stated in 12/2022 (unable to recall the date), Resident 15 entered her room, scratched her arm and tried to take her computer. Resident 77 further stated about two weeks ago Resident 15 entered her room and cursed her out. Resident 77 stated she reported Resident 77 to LVN 1 and the DON and nothing was done about it. Resident 77 stated Resident 15 returned from hospital about two to three weeks ago and continued curse Resident 77 out. Resident 77 stated she did not tell anyone of the staff because they do not do anything and that Resident 26 witnessed the aforementioned incidents with Resident 15. On 3/17/2023, at 8:48 a.m., during an interview, LVN 1 stated she remembered Resident 77 telling her that Resident 15 was acting aggressive towards Resident 77 and that Resident 77 did not feel safe. LVN 1 stated she reported the incident to Registered Nurse Supervisor 2 (RNS 2) and the DON. LVN 1 verified and stated Resident 15's aggressive behavior towards Resident 77 was a form of abuse. LVN 1 stated she was a mandated reporter and should have immediately report the incident to the ADMIN, ombudsman, CDPH, and the police. On 3/17/2023, at 8:57 a.m., during an interview, LVN 1 stated she was aware of the incidents between Resident 77 and Resident 7. LVN 1 stated Resident 77 reported to her that Resident 7 cursed at Resident 77. LVN 1 stated she notified the DON and RNS 2 and should have immediately reported the incidents to the Administrator (ADMIN), CDPH, Ombudsman, and the police. On 3/17/2023, at 9:03 a.m., during an interview, LVN 1 stated on 1/23/2023, Resident 77 reported to her (LVN 1) that Resident 7 talked loudly at Resident 77 and that Resident 77 felt scared. LVN 1 further stated she did not notify the Ombudsman, CDPH, and police on 1/23/2023. LVN 1 stated she informed the DON and RNS 2 of the incident between Resident 77 and Resident 7. On 3/17/2023, at 9:19 a.m., during an interview, the DON stated all allegations of abuse must be immediately reported to the ombudsman, CDPH, and the police. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 7 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 3/17/2023, at 11:15 a.m., during an interview, Resident 77 stated Resident 7 yelled curse words and threw cups at Resident 77 multiple times and informed to LVN 1 and the DON multiple times and nothing was done about it. On 3/17/2023, at 11:15 a.m., during an interview, Resident 7 stated he cursed and threw things at Resident 77 because Resident 77 threatened him. Resident 7 stated he overhears Resident 77 and Resident 26's conversations and they are talking about someone that sounds like me [Resident 7]. On 3/17/2023, at 1:35 p.m., during an interview, the ADMIN stated no one told him about the incidents with Resident 77. A review of the facility's in-service (required staff training) titled Abuse/Manage Aggressive Behavior dated 1/10/2023, indicated staff must report Abuse within 2 hrs (two hours) and to review facility policy on resident abuse in accordance with state and federal regulations. A review of the facility's P&P titled Abuse and Mistreatment of Residents reviewed on 8/19/2022, indicated to uphold a residence right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion . Verbal abuse is defined as any oral use of oral, written, or gesture language that willfully includes disparaging and derogatory terms to residents ., examples of verbal abuse include but are not limited to threats of harm; saying things to frighten a resident, . The Facility shall ensure reporting of all alleged and substantiated violations to the state agency and other agencies as required . Any mandated reporter, in his or her professional capacity or within the scope of his or her employment has observed or has knowledge of an incident that reasonably appears to be a physical abuse, . or is told by an elder or dependent adult that he/she has experienced behavior constituting physical abuse, or reasonably suspected abuse, shall report the known or suspected instant of abuse by telephone immediately or as soon as practically possible. The facility shall report the incident by notifying the CDPH within 2 (two) hours of the knowledge of such incident, . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 8 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop, implement, and update a person-centered care plan with measurable objectives, timeframes, and interventions for one of 25 sampled residents (Resident 49). These deficient practices had the potential to negatively affect the delivery of necessary care and services for Resident 49. Findings: A review of Resident 49's admission Record indicated the facility initially admitted Resident 49 on 1/14/2021 and readmitted Resident 9 on 10/10/2021 with diagnoses including Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and hypertension (high blood pressure). A review of Resident 49's Minimum Data Set (MDS- a standardized screening and assessment tool) dated 1/13/2023, indicated Resident 49 had limited ability to make herself understood by making simple requests and had limited ability to understand others by responding to simple, direct communication only. Resident 49 required extensive to total staff assist with transfers from bed and other activities of daily living (ADLs bed mobility, transfers from bed, eating, dressing, toilet use, and personal hygiene). The MDS further indicated Resident 49 had no natural teeth or tooth fragments and was on a mechanically altered diet (requires change in texture of food or liquids). A review of Resident 49's care plan on alteration of oral dental status dated 1/21/2021, indicated Resident 49 used dentures full upper, full lower. The care plan interventions indicated to assess Resident 49's dental condition and refer to a dentist (a person qualified to treat the diseases and conditions that affect the teeth and gums) as needed. A review of Resident 49's care plan on alteration in nutritional status revised 7/27/2021, indicated Resident 49's alteration in nutritional status was related to missing teeth and mechanically altered therapeutic diet. The care plan interventions indicated dental consult as needed. A review of Resident 49's Interdisciplinary Team (IDT - a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) meeting notes from dates 10/10/2021-3/15/2023, did not indicated IDT was completed for refusal of dentures or loss of dentures for Resident 49. A review of Resident 49's admission assessment dated [DATE] timed at 11:43 p.m., indicated Resident 49 did not have dentures upon admission to the facility. A review of Resident 49's oral/dental assessment dated [DATE] timed at 10:35 a.m., indicated nursing staff referred Resident 49 to social services for dental consult for possible replacement of lost dentures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 9 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 49's concern record form (theft/loss and grievance report) dated 10/20/2021, indicated Resident 49's family member reported missing dentures for Resident 49. A review of Resident 49's Dental notes, dated from 11/16/2021 to 11/28/2022, indicated Resident 49 very difficult to examine and refused on dates 11/16/2021, 2/17/2022, 3/11/2022, 3/23/2022, and 11/28/2022 to be examined for a dental impression. A review of Social Services progress notes, dated 2/18/2022 timed at 10:48 a.m., indicated Resident 49 was seen by a dentist on 2/17/2022, but Resident 49 declined treatment . A review of the Speech Therapy evaluation and plan of treatment, dated 12/23/2022 timed at 11:16 a.m., indicated the current diet of mechanical soft solids was discontinued and change to puree diet with thin liquids for Resident 49. On 3/14/2023, at 8:23 a.m., during a concurrent observation and interview with the Social Services Director (SSD), Resident 49 was observed eating breakfast, with no dentures. Translated by SSD, Resident 49 stated she wanted dentures. A review of Resident 49's care plan on alteration in oral/dental status secondary to Edentulous (had no natural teeth or tooth fragments) dated 3/15/2023, indicated interventions included assess dental condition and refer to dentist as indicated for Resident 49. The care plan interventions did not address Resident 49's desire to have dentures. On 03/15/2023, at 3:12 p.m., during a concurrent interview and record review, the Registered Nurse Supervisor (RNS) confirmed and stated Resident 49's last dental assessment was completed on 1/12/2023 by the facility's previous Social Services Assistant (SSA). The RNS confirmed and stated Resident 49's care plan on alteration of oral dental status dated 1/21/2021, indicated Resident 49 had both her upper and lower dentures. The RNS stated, this was the only care plan the resident (Resident 49) has on dentures. On 3/15/2023, at 3:19 p.m., during an interview, the MDS Nurse stated it was the facility's responsibility to keep and protect residents' dentures and property. The MDS nurse stated moving forward the facility will review the dentist notes, discuss the notes during the IDT meeting, and then update Resident 49's care plan. The MDS confirmed Resident 49's refusal of denture evaluations, or the recommendations of the dentist was not discussed or documented in the IDT meeting and should have been. On 3/16/2023, at 7:44 a.m., during an observation, Resident 49 was observed eating breakfast and was not wearing dentures. The SSD translated and Resident 49 stated she still wanted dentures. On 3/16/2023, at 7:46 a.m., during an interview, Certified Nursing Assistant 1 (CNA) 1 stated Resident 49 had dentures in the past, but the dentures got lost. CNA 1 stated she was not sure if Resident 49 still had dentures or not. A review of the facility's policy and procedures (P&P) titled Dental Services, reviewed on 8/19/2022, indicated routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Direct care staff will assist residents with denture care, including removing, cleaning, and storage of dentures. Dentures will be protected from loss or damage to the extent practicable, while being stored. Lost or damaged dentures will be replaced at the resident's expense unless an employee or contractor of the facility is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 10 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 responsible for accidentally or intentionally damaging the dentures. Level of Harm - Minimal harm or potential for actual harm A review of the facility's P&P titled The Resident Care Plan, reviewed, 8/19/2022, and undated, indicated, The Care Plan shall be implemented for each resident on admission, and developed throughout the assessment process. Health care professionals involved in the care of the resident shall contribute to the residents written care plan. Professionals from each discipline right the portion of the plan that pertains to their field, including their approach to the residence current problem(s). Meetings shall be held hereafter as often as necessary to keep the plan current and effective the residents plan of care shall be reviewed at least quarterly care plans are considered comprehensive in nature and shall be reviewed in its entirety. Problems, goals, and approaches can be addressed in more than one or different areas of the plan of care. The Care Plan generally includes identification of medical, nursing, and psychosocial needs. Reassessment and change as needed to reflect current status. It is the responsibility of the Director of Nursing to ensure that each professional involved in the care of the resident is aware of the written plan of care, including its location, the current problems 'of the resident, and the goals or objectives of the plan. It is the responsibility of the licensed Nurse to ensure that the plan of care is initiated and evaluated. If a resident requires the services of a professional not currently involved in the resident's care, the assigned staff shall arrange for the appropriate services, and request the professional visit the resident; that the professional chart observations, treatment, and opinions; and that the professional contribute to the resident care plan. The Nursing care plan acts as a communication instrument between nurses and other disciplines. It contains information of importance for all nurses concerning nursing approach and problem solving. Team floor conference should be conducted at regular intervals. Problems should be discussed and entered on the plan. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 11 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide treatment and services to one of two sampled residents (Resident 110) who had history of cocaine (a powerfully addictive drug) use, was admitted to the facility with no monitoring or withdrawal services. Resident 110 left the facility against medical advice two days after the facility found a glass pipe in the resident's room. Residents Affected - Few This deficient practice had the potential for the resident to experience cocaine withdrawals, such as suicidal urges, paranoid thoughts and even temporary psychosis (disruption in thought and mental process). Findings: A review of the General Acute Care Hospital (GACH) discharge instructions, dated [DATE], indicated the need for Drug Abuse services related to resident's recent use of cocaine as a result of a positive toxicology test. Health information for suicide prevention was included in the discharge instructions. A review of Resident 110's admission Record indicated the facility initially admitted Resident 110 on 11/7/2022 and readmitted Resident 110 on 12/7/2022 with diagnoses including cocaine abuse. A review of Resident 110's care plans for smoking dated 12/7/2023, indicated Resident 110 required no supervision for smoking. A review of Resident 110's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 12/14/2022, indicated Resident 110 did not cognitive (mental ability to make decisions of daily living) impairment. A review of Resident 110's History and Physical (H&P) dated 12/8/2022, indicated Resident 110 had a history of cocaine abuse and the plan did not include interventions for cocaine problem. A review of Resident 110's care plan for Illicit (forbidden by law) Drug Use developed on 1/2/2023 (26 days after admission), indicated the goals included no illicit drug use and no negative outcomes. A review of the Multidisciplinary Progress Record dated 1/10/2023, 8 days after the care plan for Illicit Drug Use was initiated the note, indicated a Certified Nursing Assistant (CNA) reported Resident 110 had a glass pipe (a device for smoking/inhalation illicit drugs) to the Social Services Director (SSD). On 3/17/2023 at 11:07 a.m., during an interview, the Social Services Director (SSD) she verified and stated Resident 110 was discharged twice from the facility. The SSD further stated Resident 110 was homeless and missed his homeless lifestyle. The SSD verified and stated she (SSD) found a glass pipe in Resident 110's room. The SSD stated the facility did not provide any specific services when asked if the facility provided detoxification (detox - a process or period of time in which one abstains from or rids the body of toxic or unhealthy substances) services to Resident 110. On 3/17/2023 at 11:10 a.m., during an interview, the Director of Nursing (DON) stated she screens (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 12 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm residents and approves their admission to the facility. The DON further stated she reviewed Resident 110's diagnoses from GACH. The DON verified and stated Resident 110 had a history of cocaine addiction and stated no detox services were provided in the facility for the resident. The DON verified and stated she was not aware Resident 110 used drugs one week prior to being admitted at the facility. The DON stated she remembered the facility staff reporting founding a glass pipe in the resident's room. Residents Affected - Few A review of the facility's policy and procedures titled admission Procedures dated 1/2004, indicated the hospital health record should be review for the appropriate admitting diagnosis to determine the covered services for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 13 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, for one of three sampled residents (Resident 10), the facility failed to provide necessary interventions consistent with the resident's needs, goals and professional standards of practice, to prevent formation of and promote healing of pressure ulcer (localized injury to the skin and or underlying tissue usually over a bony prominence because of pressure or pressure in combination with shear-layers are laterally shifted in relation to each other, and or friction-surfaces sliding against each other) by failing to: Residents Affected - Some 1. Assess and document Resident 10's weekly skin assessment, 2. Ensure Resident 10's Low air Loss mattress (LAL -a pressure relieving mattress for the management of pressure ulcers) was set at the appropriate pressure per the manufacture's guidance; and 3. Reposition Resident 10 every two hours according to Resident 10's Documentation Survey Report. These deficient practices had the potential to delay provision of necessary care and services and had the potential to delay for pressure ulcer healing for Resident 10. Findings: A review of Resident 10's admission Record indicated the facility initially admitted Resident 10 on 2/12/2020 and readmitted Resident 10 on 6/23/2021 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), and diabetes mellitus (high blood sugar). A review of Resident 10's Monthly weight report indicated Resident 10's weight were as follows: 1/2023 - 92.0 pounds (lbs- unit of measure), 2/2023 - 92.0 lbs; and 3/2023 - 93.0 lbs. A review of the manufacturer's LAL (Low Air Loss) Model: Comfort Adjust Setting indicated Comfort Setting Based on Weight (Quick Reference) were as follows: Firmest Setting =LED Light (8) = 310 pounds (lbs -unit of measure) to 350 lbs LED Light (7) = 275 lbs to 310 lbs LED Light (6) = 240 lbs to 275 lbs LED Light (5) = 205 lbs to 240 lbs LED Light (4) = 170 lbs to 205 lbs LED Light (3) = 135 lbs to 170 lbs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 14 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 LED Light (2) = 100 lbs to 135 lbs Level of Harm - Minimal harm or potential for actual harm Softest Setting = LED Light (1) = 0 lbs to 100 lbs Residents Affected - Some A review of Resident 10's History and Physical (H&P) dated 3/6/2022, indicated Resident 10 did not have the capacity to understand and make decisions. A review of Resident 10's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 3/9/2023, indicated Resident 10 was cognitively (mental ability to make decisions of daily living) severely impaired. The MDS indicated Resident 10 was totally dependent for bed mobility, dressing and toilet use. A review of Resident 10's Care Plan for Risk for developing redness, pressure sore, skin tears, skin abrasions, blister, and other types of skin breakdown initiated 6/15/2021 and revised on 10/6/2022, indicated the goal was to minimize the risk of skin breakdown/pressure sore daily and interventions that included weekly body check A review of Resident 10's Skin Progress Reports dated 12/27/2022, indicated on 8/30/2022, Resident 10 was observed for the first time with a sacrum (large triangle shaped bone in the lower spine that forms part of the pelvis) pressure ulcer with measurement of 2.5 centimeters (cm - unit of measurement) length and 2 cm width. The skin progress reports indicated the therapeutic measures included LAL mattress, turning/repositioning, pain management, incontinent care, supplemental medications, and nutritional support. A review of Resident 10's Weekly Progress Report completed on 1/03/2023, indicated Resident 10's pressure ulcer had resolved. A review of Resident 10's Weekly Body Check completed on 1/6/2023, 1/13/2023, 1/20/2023 and 1/27/2023, indicated Resident 10 had generalized body Tinea corporis (a superficial fungal infection of the skin). There was no documented evidence of body check assessments done for the month of 6/2023 and 3/2023. A review of Resident 10's Documentation Survey Report dated 2/2023, indicated intervention/task included to monitor, turn, and reposition every two hours or as needed for Resident 10. A review of Resident 10's wound risk assessment dated [DATE] at 09:37 a.m., indicated residents 10's Braden score of 16 the instructions stated if the score is 8 or greater, the resident should be considered as high risk for skin breakdown and the predisposition conditions indicated Resident 10 required assistance or is totally dependent with bed mobility. On 3/14/2023 at 8:25 a.m., during an observation, Resident 10 was lying in the supine (lying face up) position on a LAL mattress. The LAL mattress machine had four led lights fully lit and on the fifth light partially lit at the base of the LAL machine. On 3/14/2023 at 10:35 a.m., during an observation, Resident 10 was lying in the supine position. On 3/14/2023 at 11:25 a.m., during an observation and interview with Certified Nurse assistant 4 (CNA 4), Resident 10 was seen lying in supine position. CNA 4 stated Resident 10 had a pressure ulcer above the buttocks and the treatment nurse provides wound (pressure ulcer) care. CNA 4 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 15 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Resident 10 needs to be repositioned every two hours to prevent pressure ulcers. Level of Harm - Minimal harm or potential for actual harm On 3/14/2023 at 12:27 p.m., during an observation and interview with Treatment Nurse 1 (TN 1), Resident 10's Documentation Survey Report was reviewed. TN 1 stated Resident 10 had a stage three pressure ulcer (a wound that extends through the second layer of skin and into the fatty subcutaneous), required Resident 10 repositioning every two hours to prevent worsening of pressure ulcer. TN stated Resident 10 needed to be on soft setting for the LAL mattress to promote wound healing. Residents Affected - Some On 3/15/2023 at 1:47 p.m., during a concurrent interview and record review with Treatment Nurse 2 (TN 2), the LAL mattress guide was reviewed and Resident 10's weights were reviewed. TN 2 stated resident 10's weight was 93 lbs, Resident 10's LAL mattress settings should have been on light two because each light is fifty pounds. It could get worse or something. On 3/15/2023 at 12:29 p.m., during a concurrent interview and record review with RNS 1, Resident 10's medical chart was reviewed. RNS 1 stated residents need to be repositioned every two hours to prevent worsening of pressure ulcers. RNS 1 stated residents need to have weekly skin check assessment however, there is no documented evidence of the weekly skin check from 1/3/2023 to 2/28/2028 It was not done, it should have been done. I only see a skin progress note for 2/28/2023 showing a redeveloped pressure ulcer. RNS 1 stated weekly skin checks should have been done to easily determine if there is a pressure ulcer so it would not progress to stage three. On 3/17/2023 at 11:18 a.m., during a concurrent interview and record review with the MDS nurse, the facility's manufacturer LAL guide was reviewed. The MDS nurse stated Resident 10's weight for the last three months was steady in the 90's and based on the manufacturer's LAL (Low Air Loss) Model: Comfort Adjust Setting guide, indicated Comfort Setting Based on Weight (Quick Reference), Resident 10 should have been set to led light one for zero lbs to 100 lbs. A review of the facility's undated policy and procedures (P&P), titled Pressure Reducing Mattress, indicated if alternating pressure mattress was installed, check tubes for proper functioning. A review of the facility's policy and procedures (P&P), titled Procedure: Body Checks, indicated the objective to help reduce skin impairment in the geriatric residents. Residents' loose sensitivity in their skin and may not feel discomfort until it is too late, and a condition has become severe. It is important to inspect these Residents during daily care and also on a weekly basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 16 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infection (UTI - an infection that can occur in any area of the urinary tract, including the ureters, bladder, kidneys, or urethra) and skin breakdown for two of 25 sampled residents (Residents 32 and 103) by: 1. Failing to provide all the preventative measures to prevent a urinary tract infection and skin breakdown for Residents 32 and 103. 2. Failing to provide proper peri-care in a timely manner for Residents 32 and 103, who have a history of UTI. These deficient practices had the potential for Residents 32 and 103 to develop UTIs and skin breakdown. Findings: 1. A review of Resident 103's admission record indicated Resident 103 was admitted to the facility on [DATE], with diagnoses that included multiple fractures (A complete or partial break in a bone) of the shaft of the right tibia and fibula, right wrist, humerus of the right arm, reduced mobility, muscle weakness, and history of falls. A review of Resident 103's Minimum Data Set (MDS - a standard assessment and care screening tool) date 5/7/2023, indicated Resident 103's cognition was intact (being able to follow two simple commands), total dependent for toilet use, and was incontinent of bladder and bowel. A review of Resident 103's medication administration record indicated resident was started on Keflex (antibiotic to treat urine infections) 500 milligrams (mg, unit of measurement), 1 capsule by mouth two times a day for 5 days on 3/6/2023. A review of Resident 103's care plan titled, Alteration in Elimination r/t Bowel and Bladder, with no date initiated, indicated [Resident 103] was always incontinent. The resident's goal included to be clean, dry, and odor-free daily and to minimize the risk of skin breakdown daily. The interventions included to change brief promptly when soiled, keep clean, dry and odor-free, observe good peri-care, monitor for signs and symptoms of UTI. On 3/14/2023, at 12:35 p.m., during an observation, Resident 103 was sitting up in bed, awake, alert, and oriented to person, place, and time. During a concurrent interview, Resident 103 stated no one had come and changed her. Resident asked if I could find someone to change her. Resident was advised to use her call light. Resident turned on her call light and stated, they will check on others and not me. On3/14/2023, at 1:01 p.m., during an observation, lunch trays arrived for Residents 2 and 103. On 3/16/2023 at 12:56 p.m., during an interview, Resident 103 stated, yesterday was a difficult day after I saw you. I had a sick tummy. You see I had an emergency. I was asking for diaper change (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 17 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 because I had poop all over me. The nurse told me it's dinnertime and just walked away. Level of Harm - Minimal harm or potential for actual harm 2. A review of Resident 32's admission record indicated Resident 32 was admitted to the facility on [DATE], with diagnoses that included heart failure, presence of cardiac pacemaker (A pacemaker is a small device that's placed in the chest to help control the heartbeat), respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), unspecified with hypoxia (occurs when you do not have enough oxygen in your blood), diabetes (a metabolic disease, involving inappropriately elevated blood glucose levels), hypertension (is a condition in which the blood vessels have persistently raised pressure), reduced mobility, generalized weakness, and functional quadriplegia (complete immobility due to severe physical disability or frailty). Residents Affected - Some A review of Resident 32's MDS date 12/29/2022, indicated Resident 32 had no cognitive impairment (confusion or memory loss that is happening more often or is getting worse during the past 12 months), required extensive assistance for toilet use, and was incontinent of bladder and bowel. A review of Resident 32's medication administration record indicated Cipro (medication used to treat infections) 500 mg was started for a urine infection 12/28/2022. A review of Resident 32's care plan titled, Risk for Skin Breakdown related to Incontinence of Bowel and Bladder, initiated on1/5/2023 with resident's goal to minimize the risk of skin breakdown/pressure sore daily. The interventions included provide good skin care every shift and clean after each episode of incontinence. On3/14/2023, at 12:28 p.m., during an observation and a concurrent interview with the Treatment Nurse 1 (TN 1), Resident 32 was observed sitting up in bed, awake, alert, and oriented to person, place, and time. Resident stated she had been sitting in wet brief for hours. TN 1 stated the nurse was late because they were passing trays. On 3/14/2023, at 12:42 p.m., during an observation, Certified Nurse Assistant 2 (CNA 2) did not address Resident 103 when call light was answered, instead she checked on resident 16 and did not address Resident 103. CNA 2 was observed putting a towel over Resident 103 in preparation for her lunch tray. There were no lunch trays observed at that time. During a concurrent interview, CNA 2 stated, I was trained if it's not breakfast or lunch, I have to wait to change them before I bring out the barrels. Once they are done with their meal then that will be my first thing to do. CNA further stated she can't bring out the carts for dirty linen and trash because she has to prevent contamination from the dirty barrels and the trays. CNA 2 further stated, I personally will change them right then and there if it isn't during breakfast or lunch. On 3/16/2023, at 10:13 a.m., during an interview, the Director of Staff Development (DSD) stated when residents are soiled change them immediately. The DSD further stated if it was close to mealtime and trays have not been passed out yet then they need to clean them and it was unacceptable if they tell residents to wait until after lunch. Residents should be changed because you don't want the smell while you are eating and its good skin care. The DSD further stated, staff should not use infection control as an excuse. The inservices per DSD interview was to change residents immediately. The facility's policy and procedures regarding timely incontinet care was requested from the DSD. The facility was unable to provide a P & P for timely incontinent care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 18 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow up on the recommendation from the pharmacy consultant medication regimen review (MRR- a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for a laboratory monitoring, for one of five sampled residents (Resident 66) reviewed for potential unnecessary medications. For Resident 66, a blood test (HgA1c- also known as the hemoglobin A1C test-is a simple blood test that measures your average blood sugar levels over the past 3 months) was not performed as recommended for the use of insulin. This deficient practice had the potential for unnecessary medication use leading to an adverse drug reaction (undesirable or non-therapeutic effect of the medication) which could result in harm and injuries to the resident. Findings: A review of admission Record indicated Resident 66 was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes (a chronic health condition that affects how your body turns food into energy), Acute Kidney Failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes),Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) A review of the Minimum Data Set (MDS-a standardized resident assessment and care screening tool), dated 2/17/2023, indicated Resident 66 was sometimes able to understand others and required extensive assistance (resident able to participate in activity) with one person assist for toilet use and personal hygiene. A review of the Pharmacy consultant medication regimen review (MRR) dated 1/04/2023, indicated the recommendation to order laboratory testing. The MRR further indicated This resident has orders for sliding scale insulin Aspart (a rapid acting, human insulin that the FDA approved for the treatment of type-1 and type-2 diabetes) three times a day, before meal and at bedtime. The new Beer's Criteria recommends avoidance of sliding scale insulin in all care settings due to a higher risk of hypoglycemia (low blood glucose, or blood sugar) without improvement in hypoglycemia management. There was neither documentation that the physician was notified, nor any other evidence a laboratory testing was done. During an interview on 3/16/2023 at 2:15 p.m., with Director of Nursing (DON), the DON reviewed Resident 66's medical records and verified there were no orders or progress notes for the follow up of MRR recommendation made on 1/4/2023, for a HgA1c lab testing. A review of the facility's policy and procedure titled Consultant Pharmacist Report Medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 19 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Regimen Review (monthly report) dated December 2016, indicated the consultant pharmacist performs a comprehensive medication regimen review (MRR) at lease monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 20 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide necessary dental services as indicated on the dental consult report for one of two sampled Residents (Resident 41). Residents Affected - Few This deficient practice had the potential to result in the resident having the inability to effectively chew foods, weight loss, lack of energy and loss of muscle mass. Findings: A review of Resident 41's admission Record indicated that the facility admitted Resident 41 on 2/3/2021 with diagnoses including diabetes mellitus (high blood sugar), arteriosclerotic heart disease (ASHD- a thickening and hardening of the walls of the coronary arteries), and major depressive disorder. A review of Resident 41's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 10/13/2022, indicated Resident 1 was cognitively (relating to mental ability to make decisions of daily living) intact. The MDS indicated Resident 41 required supervision for bed mobility, limited assistance for transfers, dressing and independent with bed mobility. A review of Resident 41's Dental Physician order dated 11/28/2022, indicated the treatment recommendation for upper and lower extraction then full upper and partial lower dentures after extraction. A review of Resident 41's Social Services Assessment (Dental) v1.1 dates 1/31/2023 at 10:58 a.m., indicated Resident 41 had mouth pain, with broken, loose, or carious teeth Resident was experiencing some mouth pain due to broken teeth, Dentist to extract. On 3/14/2023 at 12:15 p.m., Resident 41 was observed with loose upper front teeth. During a concurrent interview, Resident 41 stated the Dentist was aware of his upper frontal loose teeth when he saw the Dentist two months ago, however, he had not heard anything since then from the facility staff or the Dentist. On 3/16/2023 at 8:35 a.m., during a concurrent interview and record review of Social Services Assessment (Dental) v1.1 and Dental Physician Orders, Social Services Director (SSD) stated she was aware of Resident 41's loose upper front teeth and the dental treatment recommendations to extract then full upper and partial lower dentures thereafter. The SSD stated she did not follow up on the dental treatment recommendation made on 11/28/2022. The SSD answered yes stating she should have followed up because things like this (missed order) can happen and affect the residents body condition. On 3/16/2023 at 9:09 a.m., during a concurrent interview and record review of Social Services Assessment (Dental) v1.1 and Dental Physician Orders with Minimum Data Set Nurse (MDS), the MDS Nurse stated there was no documented evidence that a follow up was made with the dentist regarding the treatment recommendations made on 11/28/2022. The MDS Nurse also stated yes they (SS-socail services) should have followed up, adding it is important for the Residents chewing benefits, to make sure the Resident is comfortable with chewing. Prevent delay in care. On 3/16/2023 at 11:02 a.m., during a concurrent interview and record review of Social Services Assessment (Dental) v1.1 and Dental Physician Orders, the Director of Nursing (DON) stated the treatment recommendations made on 11/28/2022 was not followed up with Dentist. The DON also stated to prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 21 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 pain, worsening issues . eating is important. Level of Harm - Minimal harm or potential for actual harm On 3/17/2023 at 10:48 a.m., during an interview with the Doctor of Dental Surgery (DDS), the DDS stated a copy of the treatment recommendations was given to the SSD and the SW (social worker) to follow up with their office for approval and Lumina. Residents Affected - Few A review of the facility's policy and procedures (P&P), titled Dental Services, revised 12/2016, the policy statement indicated routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. A review of the facility's policy and procedures (P&P), titled Availability of Services, Dental revised 8/2007, indicated Social Services will be responsible for making necessary dental appointments. A review of the facility's policy and procedures (P&P), titled Emergency Dental Care revised 4/2007, indicated Emergency dental services include services needed to treat an episode of acute pain in teeth, gums, or palate: broken, or otherwise damaged teeth, or any problem of the oral cavity appropriately treated by a dentist that requires immediate attention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 22 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to follow the menu portions sizes during lunch tray services by not using the correct size serving utensil for Kimchi (a traditional Korean side dish of salted and fermented vegetables, such as napa cabbage and Korean radish) resulting in 40 out of 40 residents on regular texture diet not receiving the correct portion size. The facility also failed to ensure the correct portion of beef fritter patties were severed to 5 out of 5 residents. These deficient practices had the potential for residents on a regular texture diet not to receive the correct amount of caloric intake and protein in their diet. Findings: During an observation of try line services in the kitchen on 3/15/2023 at 12:20 PM, Dietary Aid (DA) stated that she scooped the Kimchi with the green scoop (serving utensil) and pointed to the green scoop, which is the number 12 scoop. A review of the daily menu called for Kimchi to be served with a size 16 scoop, the blue handled scoop. During an interview on 3/15/2023 at 12:22 PM with the Dietary Supervisor (DS), the DS stated that the Kimchi should have been prepared with the number 16 scoop, the blue handled scoop. During an observation of tray line on 3/15/2023 at 12:30 PM, [NAME] (CK) was preparing the regular lunch trays with one beef fritter patty for five (5) observed trays. During a concurrent interview, the CK stated that she thought the menu called for one beef fritter patty. After the review of the daily menu indicated two (2) beef fritter patties, the CK proceeded to place two beef fritter patties on the regular trays. During a concurrent observation and interview, the DS stated that the menu indicated 2 beef fritter patties for portion size. The DS weighted one beef fritter patty that weighed 2.8 ounces. A review of the facility policy and procedure titled Menu, dated 2019, indicated, the standard menu will insure nutritional adequacy of all diets, offer a variety of food in adequate amounts at each meal and a standardized food productions .Menus are planned to meet the recommended dietary allowances of the food and nutrition board, national research council, adjusted to the age, activity and environment of the group involved .The menus will be prepared as written using standardized recipes. The dietary services supervisor and cooks are trained and responsible for the preparation and service of therapeutic diets prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 23 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple resident bedrooms for 39 of 45 resident rooms (Rooms 3, 5, 6, 8, 9, 10, 12, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45). rooms [ROOM NUMBER] had two beds inside the room. Rooms 8, 9, 10, 12, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45 had three beds inside the room. This deficient practice had the potential to result in inadequate useable living space for all the residents and working space for the health caregivers, which could affect the quality of life for the residents. Findings: A review of the Request for Room Size Waiver letter submitted by the Administrator, dated 3/17/2023, indicated 39 resident rooms in the facility do not meet the requirement of at least 80 square feet per resident per federal regulation. The letter indicated the resident beds are in accordance with the special needs of the residents and will not adversely affect resident's health and safety and do not impede the ability of the residents in the room to obtain their highest practicable well-being. The following rooms provided are less than 80 square feet per resident: Rooms # Beds Floor Area Sq. Ft. Sq. Ft/Resident 3 2 153.7 76.85 5 2 158.05 79.025 6 2 158.05 79.025 7 3 206.1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 24 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 68.7 Level of Harm - Potential for minimal harm 8 3 206.1 Residents Affected - Some 68.7 9 3 206.1 68.7 10 3 206.1 68.7 12 3 206.1 68.7 15 3 206.1 68.7 16 3 206.1 68.7 17 3 206.1 68.7 18 3 206.1 68.7 19 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 25 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 3 206.1 Level of Harm - Potential for minimal harm 68.7 20 Residents Affected - Some 3 213.57 71.19 21 3 216.45 72.15 22 3 213.57 71.19 23 3 206.28 68.76 24 3 206.28 68.76 25 3 206.28 68.76 26 3 210.9 70.3 27 3 199.1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 26 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 66.4 Level of Harm - Potential for minimal harm 28 3 209 Residents Affected - Some 69.7 29 3 209 69.7 30 3 206.28 68.76 31 3 209 69.7 32 3 209 69.7 33 3 209 69.7 34 3 210.9 70.3 35 3 209 69.7 36 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 27 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 3 Level of Harm - Potential for minimal harm 209 69.7 Residents Affected - Some 37 3 209 69.7 38 3 204.12 68.04 39 3 204.12 68.04 40 3 204.12 68.04 41 3 204.12 68.04 42 3 204.12 68.04 43 3 204.12 68.04 44 3 210.9 70.3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 28 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 45 Level of Harm - Potential for minimal harm 3 210.9 70.3 Residents Affected - Some According to the federal regulation, the minimum square footage for a 2-bed room is at least 160 sq. ft. and the minimum square footage for a 3-bed room is at least 240 sq. ft. During the recertification survey on 3/14/2023, staff interviews indicated there were no concerns regarding the size of the aforementioned rooms. During the Resident Council meeting on 3/15/2023, at 1:30 p.m., no concerns were brought up by the residents regarding the size of the rooms. During the multiple observations of the residents' rooms from 3/14/2023 to 3/17/2023, the residents had ample space to move freely inside the rooms. There were sufficient spaces to provide freedom of movement for the residents and for nursing staff to provide care to the residents. There were also sufficient spaces for beds, side tables and resident care equipment in the rooms. On 3/17/2023 at 10:48 a.m., during a concurrent interview and observation of the room measurements and space with the Administrator and Maintenance Supervisor, they both stated the facility had submitted a written request for continued room waiver. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 29 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the facility was free from the cockroach infestations. Residents Affected - Some These deficient practices had the potential to result in sickness among 111 residents in the facility due to the bacteria carried by cockroaches, which were observed in the kitchen and one resident room. Findings: A review of the undated article entitled Effective Management of Cockroach Infestations from the County of Los Angeles Department of Public Health Vector Management Program indicated, Cockroaches are nocturnal .and most like warm hiding places with access to water. The article indicated monitoring cockroaches included Common signs to watch for are fecal matter (e.g., dark sports or smears), cast skins (shed skin when an immature cockroach grows), egg cases, and live or dead cockroaches. During an initial tour on 3/14/2023 at 11:30 AM in one of resident rooms, two live cockroaches were observed on the floor next to the resident's bed. During a kitchen tour on 3/15/2023 at 11:45 AM, one live cockroach was observed in a bait trap under the sink and two live cockroaches were observed in a second bait trap under the sink. During a concurrent interview with Dietary Supervisor (DS), the DS stated that he was unaware of any cockroaches in the traps and was informed of what traps the cockroaches were in. A review of the Pest Control Services Report from the facility dated 3/16/2023 at 5:34 AM, indicated a service technician inspected the facility and indicated, found American roach activity in the kitchen device, inspected, all areas for possible activity no signs of pest activity found. Will highly recommend for the kitchen back door exit to dumpster/alley way be fixed; door has openings around the frame. Exterior alley has rodent and pest activity and with gaps in the doors it can favor rodents and pest as entry ways into the facility. Trees around the property will recommend for branches to be trimmed three to four feet away from the structure, areas can favor rodent/wildlife and pest walkways into the facility. During an interview on 3/16/2023 at 12:00 PM with Maintenance Supervisor (MS), the MS stated that on 3/16/2023, he toured the facility with the service technician from the pest control services and is currently working on completing the recommendations from the service technician. During an interview on 3/16/2023 at 1:30 PM with Administrator (ADM), the ADM stated that the facility does have a regular pest control services to service the building regularly. The ADM also stated the company did come out this morning to complete an inspection. The ADM further stated the facility will be following the recommendations from the pest control services to make sure the facility does not have any further roaches within the facility. A review of the facility policy and procedure titled Integrated Pest Management Program, undated, stated Key elements of an Integrated Pest Management program takes cooperation and sharing information between several hospital departments and pest control technician .Monitoring regular site inspects and pest trappings to help determine whether pest are present and whether they are present at a level that requires measuring .Roaches Sanitation is a must, food in patient rooms must be in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 30 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete pest-proof airtight container, no corrugated cardboard boxes allowed in patient rooms, dead roaches must be vacuumed out of bedside cabinets to prevent re-infestation .Corrugated cardboard boxes must be removed from storerooms, no personnel items are to be stored in the kitchens, floors are to be kept clean of food and grease build up, this includes under tables and stoves, if not any roaches baiting program will not work, kitchen walls, under steam tables, dishwashing area, behind stove, around door frames must be caulked and sealed to prevent nesting and places for roaches. Event ID: Facility ID: 056326 If continuation sheet Page 31 of 32 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington Convalescent Hospital 845 S.Burlington Avenue Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to ensure one of five Certified Nursing Assistants (CNA 1) was provided in-services and maintain a process to track CNA's participation in the required trainings. This deficient practice had the potential to result in incompetency of nursing skills, leading to inadequate resident care. Findings: On 3/17/2023 at 2:30 p.m., during a concurrent interview and record review of the interview binder with the Director of Staff Development (DSD), the DSD stated Certified Nursing Assistant 1 (CNA 1) was only provided in-services on biohazard and abuse, missed in-services on falls, catheter care and infection control. The DSD stated, there is no log to track the in-services given to CNA's and that in-services are important to fix the issue (inadequacy) to make sure it does not happen again. A review of the facility's policy and procedures (P&P), titled Inservice Training, All Staff, revised 8/2022, indicated Policy statement: All staff must participate in initial orientation and annual Inservice training. The primary objective of the Inservice training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 32 of 32