Inspection·December 21, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (L) of 02 by non-rebreather mask. SpO2 went up 88 but Resident 1 still appeared to have difficulty breathing. 911 (a phone number used to contact emergency services) was called by supervisor (RN2) at3: 59a.m. Paramedics arrived and assessed Resident 1 at 4:05a.m. Paramedic transferred Resident 1 to the Acute care for higher level of care. A review of Resident 1 ' s GACH emergency room (ER) admission records dated 12/13/2023, indicated Resident 1 was found to be in respiratory distress, and subsequently taken to the ER. The GACH records indicated that on arrival to the ER patient had a cardiac arrest (heart suddenly and unexpectedly stops beating), when Resident 1 was being endotracheally intubated (a medical procedure in which a flexible tube is inserted through the mouth or nose and into the windpipe to establish and maintain an open airway) a rubber hand glove was found in intraorally (inside the mouth) in the posterior pharynx (back of the throat). After intubation patient had a return of spontaneous circulation (ROSC). During an interview on 12/14/2023 at 10:20 a.m., Assistant Director of Nursing (ADON) stated, Resident 1 was admitted to the facility on [DATE] at approximately 11p.m. and was transferred out to GACH1 for a higher level of care after developing sudden shortness of breath that could not be corrected with supplemental oxygen. The ADON stated two police officers arrived at the on 12/13/2023 at 8:30 a.m., Police officers asked ADON if an elderly female Resident was transferred by the facility to GACH1, ADON stated she acknowledged to the Police that Resident 1 was transferred to Acute care, Police asked why the Resident was transferred to the hospital, ADON stated she told the Police Resident 1 developed shortness of breath and that is why she was sent to the hospital for higher level of care. ADON states the Police informed ADON that GACH1 reported to the Police that Resident 1 was found with a glove in her mouth when she (Resident 1) arrived and was assessed in the emergency room. ADON stated Police asked to be shown the room where Resident 1 was residing, ADON states she accompanied the Police to Resident 1 ' s room, the Police observed an open hand glove box by Resident 1 ' s nightstand and then the Police left the facility. During an interview on 12/14/2023 at 10:53 a.m., Director of Nursing (DON) stated Resident 1 had been a resident at the facility for a long time and had just been re-admitted to back to the facility on [DATE] at 11:10 p.m. from GACH2 where the resident was transferred after a fall and possible fracture on 12/5/2023 for a higher level of care. DON stated Resident 1 was admitted and assessed immediately after re-admission to the facility and was medically stable (conscious and comfortable with vital signs within normal limits). DON stated Resident 1 developed sudden shortness of breath at 3:30 a.m. (4.5 hours after admission) and became hypoxic (low levels of oxygen in the body tissues, causing changes in breathing with oxygen saturation of 75%) normal oxygen saturation is between 95%-100%. Resident 1 was immediately started on supplemental oxygen (a colorless odorless gas used as a safe and standard medical treatment for low blood oxygen), Resident 1 ' s oxygen levels improved slightly to 88% but was not therapeutic enough resolve the effects of low oxygen levels. Emergency services were called, paramedics arrived at the facility and assessed Resident 1 then transferred Resident 1 to GACH 1 for higher level of care. On 12/14/2023 at 11:30 a.m. during a telephone interview with Registered Nurse 1 (RN1), RN1 stated Resident 1 was re-admitted to the facility at 11:10 p.m. by the supervisor (RN2), RN1 states, Resident 1 seemed confused but was not short of breath, RN1 states Resident 1 spoke to her in their native language stating that she (Resident 1) needed to go to the bathroom despite having a foley catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage), Resident 1 also stated to RN1 that someone was calling her and that she (Resident 1) needed to go home. RN1 states she kept a close watch on Resident 1 because of Resident 1 history of falls and dementia diagnosis. RN 1 stated at 3a.m., she (RN1) and Certified Nurse Assistant (CNA1) helped Resident 1 put (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 2 of 3 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 12/21/2023 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 0689 on incontinence brief. RN1 gave Resident 1 some water, Resident 1 swallowed the water without difficulty. Level of Harm - Minimal harm or potential for actual harm RN1 stated at 3:45 a.m. she (RN1) checked on Resident 1 and observed her (Resident 1) seated on the edge of the bed on the left side, Resident 1 looked like she was going to stand up. RN1 assisted Resident 1 back to bed, adjusted her foley catheter, and raised the head of her bed because she observed Resident 1 to be out of breath. RN1 stated Resident 1 had her mouth open, was trying to breath but was not coughing or holding her neck as if to signal she was choking. Residents Affected - Few RN1 states she called RN2, RN2 placed Resident 1 on 15 liters (l) of oxygen per min (l/min) via a non-rebreather mask (a device used to give oxygen in an emergency) 911 was called. Paramedics arrived, assessed Resident 1, and transferred her to the hospital for a higher level of care. On 12/19/2023, at 10:27 a.m. during a telephone interview, MD1 stated if a Resident was to develop a sudden onset of acute shortness of breath, he would expect facility to assess vital signs, perform a physical assessment including heart and lungs sounds, assess resident ' s mental status and check oral cavity to ensure there is nothing occluding resident breathing. On 12/20/2023, at 1:35 p.m. during a telephone interview, MD2 stated Resident 1 was brought to ER via ambulance, upon arrival, MD2 states Resident 1 ' s mouth was closed, Resident was not alert, was not coughing, appeared weak and unstable, was unable to speak, Resident 1 ' s blood pressure dropped, Resident 1, became unresponsive, went into cardiac arrest and when she (Resident 1) was being endotracheally intubated, a rubber glove was found intraorally and was removed. After intubation Resident 1 had return of spontaneous circulation (ROSC). MD2 further stated the glove was (off white) opaque in color and was not the rubber kind used in the hospital. A review of the facility's policy and procedure, titled Safety and Supervision of Resident revised July 2017 under subtitle individualized, Resident-Centered Approach to safety states facility individualized, resident-centered approach to safety addresses safety and accident hazards for individual resident. Policy further states, interdisciplinary care team shall analyze information obtained from assessment sand observations to identify specific accidents hazards or risks for individual residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 3 of 3