Health inspection·February 9, 2024

F 0558 stated I am not able to find the call light. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 2/6/2024 at 9:52 A.M., with the TN, the TN stated Resident 1's call button was at the head of Resident 11's bed, it's not within reach of the resident, it (Call button) needed to be within reach. The TN further stated potential adverse outcome of not having the call button within reach is that resident may not be able to call for assistance which may lead to falls. Residents Affected - Some During an interview on 2/9/2024 at 10:30 A.M., with Director of Nursing (DON), the DON stated call buttons need to be within reach of the residents to ensure that they can reach staff for help; not having call buttons within reach of the residents may lead to fall. A review of the facility's policy and procedure titled Answering the Call Light, Revised 3/2023, indicated ensure that the call light is accessible to the resident when in bed or wheelchair in room, from the toilet or shower room in necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 2 of 18 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 02/09/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview, and record review, the facility failed to ensure that advanced healthcare directives (legal documents that outline an individual's preferences regarding major medical decision) information was provided to the resident representative (RP) for one of eight sampled residents (Resident 11). This deficient practice had a potential to violate the resident's rights related to the provision of health care. Findings: A review of Resident 11's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with medical diagnoses that included dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), diabetes mellitus (DM- a metabolic disease, involving inappropriately elevated blood glucose[sugar] levels), and hypertension (HTN -elevated blood pressure). A review of Resident 11's History and Physical (H&P-a comprehensive formal assessment by a physician), dated 7/17/2023, indicated Resident 11 did not have the capacity to understand and make decisions. A review of Resident 11's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/17/2023, indicated Resident 11 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and was dependent on staff for eating, toilet use, oral hygiene, and personal hygiene. During a concurrent interview and record review on 2/7/2024 at 3:00 P.M., with the Social Services Director (SSD), Resident 11's advanced directive acknowledgement form dated 6/11/2021 was reviewed. The SSD stated Resident 11 is not capable of making preferred intensity of care decisions and she (SSD) should have reached out to the resident's representative and provided the representative advance directive information regarding Resident 11's right for an advanced healthcare directive. The SSD further stated advanced healthcare directives should be addressed to ensure the residents wishes for healthcare are known by the facility and how to provide them (Resident) proper care. During an interview on 2/9/2024, at 10:40 A.M., with the Director of Nursing (DON), the DON stated advanced healthcare wishes should be completed and placed in the resident chart to ensure their wishes are known especially when they are sick. A review of the facility's policy and procedure titled Advance Directives, Revised 9/2022, indicated, The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 3 of 18 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 02/09/2024 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 0639 Maintain 15 months of resident assessments in the resident's active clinical record. 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, facility failed to obtain and retain all resident assessment for hospice (care that is focused on the comfort and quality of life for a person with a serious illness who is approaching the end of life) care in residents active record for one of three sampled residents (Resident 44). Residents Affected - Some This deficient practice had the potential for the resident not receiving needed care according to assessment and care plans. Findings: Cross Reference F849 A review of Resident 44's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with medical diagnoses that included dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), cervical spinal cord injury (affecting the head, neck region above the shoulder), and diabetes mellitus (DM- a metabolic disease, involving inappropriately elevated blood glucose[sugar] levels). A review of Resident 44's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/19/2023, indicated Resident 44 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and was dependent on staff for eating, toilet use, oral hygiene, and personal hygiene. A review of the physician's orders, dated 12/9/2023, indicated hospice care due to dementia. A review of Resident 44's Hospice binder, there were no documented records of Resident 44's hospice care plan, visiting schedule and assessments. During a concurrent interview and record review on 2/8/2024 at 2:15 P.M., with the Assistant Director of Nursing (ADON), Resident 44's Hospice binder was reviewed. The ADON stated Resident 44's hospice binder should contain the hospice visitation calendar, care plan, and assessments. The ADON stated there was no documented evidence of the hospice assessment, care plan or visitation calendar in Resident 44's hospice binder or physical chart. The ADON further stated there were no other places where these records could be found. The ADON stated they (care plan, assessments, and visitation calendar) should have been in the hospice binder or Resident 44's chart for continuity of care for the resident (Resident 44), so the facility may know when the hospice staff comes into the facility for visitation of Resident 44 and to know the plan of care of the resident (Resident 44). The ADON stated there was no specified point of contact between the hospice agency and the facility and that collaboration between the entities was a collaborated effort of all facility staff such as nurses, social services, the ADON and the Director of Nursing (DON). During an interview on 2/9/2024 at 9:26 A.M., with the Administrator for Hospice (AFH), the AFH stated, Resident 44 had been on their hospice service since 12/9/2024, and hospice visits for Resident 44 were once a week unless there are any changes. The AFH stated the hospice nurse notifies and gives a copy of orders, if any, to the assigned charge nurse of the shift during hospice visits in the facility. The AFH further stated hospice notes (assessment) are not left with the facility on the day of the visit and are only provided to the facility upon request, adding they (facility) just asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 4 of 18 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 02/09/2024 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 0639 me for those records yesterday and I emailed the records to them. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/9/2024 at 11:06 A.M., with the DON, the DON stated Resident 44's hospice binder should include the visiting calendar for the hospice staff, care plans for hospice and assessments done by hospice on the day of each visit for Resident 44. The DON stated there was no documented evidence of those documents and as the DON it is my responsibility to make sure those documents (assessments, care plans, and visitation calendar) were in the binder. The DON stated that retaining and ensuring these records are readily available is so the facility know who is coming from hospice, when they are coming and the resident's condition on the day of the visit. The DON stated not having the documents may lead to lack of continuity of care, not knowing what changes may have happened to the resident and the updated plan of care thereof. Residents Affected - Some A review of the facility's policy and procedure titled, Retention of Medical Records, revised 12/2006, indicated, Medical records shall be retained by the facility in accordance with current applicable laws. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 5 of 18 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 02/09/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and food thawing practices in the kitchen when: Residents Affected - Some a. Thawing pork at room temperature. b. One of five staff did not wear gloves during Trayline food preparation. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of bacteria from one object to another) that could lead to foodborne illness in medically compromised residents who received food from the kitchen. Findings: a. During the initial kitchen tour observation of the food preparation sink on 2/6/2024 at 7:38 A.M., pork ribs in a food container and chopped pork in food storage bags were thawing in the food preparation sink at room temperature. During an interview on 2/6/2024 at 7:48 A.M., [NAME] 1 stated the meat was pork and [NAME] 1 was preparing to cook the meat for lunch. [NAME] 1 stated that the meat should be thawed under running water. b. During observation of the Trayline food preparation on 2/7/2024 at 12:10 A.M., Dietary Aide 1 (DA1) did not wear gloves while handling food to be served directly to residents. During an interview on 2/7/2024 at 7:48 A.M., DA1 stated he would usually have gloves on, but he forgot to put them on today. DA1 stated that if he does not use gloves while handling food there is a possibility that the food could be contaminated. During an interview on 2/7/2024 at 1:41 A.M., the DS stated all staff must wear gloves during Trayline food preparation. The DS stated that all staff were trained to wear gloves when handling food during food service. The DS also stated handwashing should be performed when changing gloves and gloves soiled. The DS stated when thawing meat, the meat must not be left to thaw at room temperature; the cook must take the meat out of the freezer and thaw it under running water for about 30 minutes to 1 hour. A review of the facility's Policy and Procedures (P&P) titled Thawing Food, dated Revised 2019, indicated All food will be thawed in a safe and sanitary manner. 1. In a refrigerator at 40 degrees F or colder. Allow 2 to 3 days to defrost, depending on the quantity and weight of the product. a. All defrosted items must indicate product name and thaw date. b. Meat will be thawed on the bottom shelf below prepared or ready-to-eat foods. c. All raw meats will be thawed separately from each other, and separately from any other foods. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 6 of 18 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 02/09/2024 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 0812 Never thaw chicken and beef on the same tray. Level of Harm - Minimal harm or potential for actual harm 2. Under potable, running water at a temperature of 70 degrees F or lower, with sufficient velocity to agitate and float off loose food particles into the overflow. Residents Affected - Some 3. In a microwave if foods are to be cooked immediately following the thawing process, or when the entire cooking process will be completed in the microwave. 4. Food can be thawed as part of the cooking process. A review of the facility's Policy and Procedure (P&P) titled Sanitation and Infection Control, dated Revised 2019, indicated Disposable gloves will be worn when handling food directly with bare hands to prevent food borne illnesses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 7 of 18 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 02/09/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility failed to obtain and retain all resident assessment for hospice (care that is focused on the comfort and quality of life for a person with a serious illness who is approaching the end of life) care in residents active record for one of three sampled residents (Resident 44). This deficient practice had the potential for the resident not receiving needed care according to assessment and care plans. Findings: Cross Reference F639 A review of Resident 44's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with medical diagnoses that included dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), cervical spinal cord injury (affecting the head, neck region above the shoulder), and diabetes mellitus (DM- a metabolic disease, involving inappropriately elevated blood glucose[sugar] levels). A review of Resident 44's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/19/2023, indicated Resident 44 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and was dependent on staff for eating, toilet use, oral hygiene, and personal hygiene. A review of the physician's orders, dated 12/9/2023, indicated hospice care due to dementia. A review of Resident 44's Hospice binder, there were no documented records of Resident 44's hospice care plan, visiting schedule and assessments. During a concurrent interview and record review on 2/8/2024 at 2:15 P.M., with the Assistant Director of Nursing (ADON), Resident 44's Hospice binder was reviewed. The ADON stated Resident 44's hospice binder should contain the hospice visitation calendar, care plan, and assessments. The ADON stated there was no documented evidence of the hospice assessment, care plan or visitation calendar in Resident 44's hospice binder or physical chart. The ADON further stated there were no other places where these records could be found. The ADON stated they (care plan, assessments, and visitation calendar) should have been in the hospice binder or Resident 44's chart for continuity of care for the resident (Resident 44), so the facility may know when the hospice staff comes into the facility for visitation of Resident 44 and to know the plan of care of the resident (Resident 44). The ADON stated there was no specified point of contact between the hospice agency and the facility and that collaboration between the entities was a collaborated effort of all facility staff such as nurses, social services, the ADON and the Director of Nursing (DON). During an interview on 2/9/2024 at 9:26 A.M., with the Administrator for Hospice (AFH), the AFH stated, Resident 44 had been on their hospice service since 12/9/2024, and hospice visits for Resident 44 were once a week unless there are any changes. The AFH stated the hospice nurse notifies and gives a copy of orders, if any, to the assigned charge nurse of the shift during hospice visits in the facility. The AFH further stated hospice notes (assessment) are not left with the facility on the day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 8 of 18 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 02/09/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of the visit and are only provided to the facility upon request, adding they (facility) just asked me for those records yesterday and I emailed the records to them. During an interview on 2/9/2024 at 11:06 A.M., with the DON, the DON stated Resident 44's hospice binder should include the visiting calendar for the hospice staff, care plans for hospice and assessments done by hospice on the day of each visit for Resident 44. The DON stated there was no documented evidence of those documents and as the DON it is my responsibility to make sure those documents (assessments, care plans, and visitation calendar) were in the binder. The DON stated that retaining and ensuring these records are readily available is so the facility know who is coming from hospice, when they are coming and the resident's condition on the day of the visit. The DON stated not having the documents may lead to lack of continuity of care, not knowing what changes may have happened to the resident and the updated plan of care thereof. A review of the facility's policy and procedure titled, Retention of Medical Records, revised 12/2006, indicated, Medical records shall be retained by the facility in accordance with current applicable laws. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 9 of 18 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 02/09/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain the handwashing sink for kitchen area in a safe operating condition. Residents Affected - Some This deficient practice had the potential for kitchen staff not being able to perform hand washing which was required for staff before starting work in the kitchen and before and after handling foods. Findings: During the initial kitchen tour on 2/6/2024 at 7:38 A.M., at the entrance to the kitchen area, Dietary Supervisor (DS) stated the cold-water faucet at the handwashing sink had been leaking for over two weeks. During an observation on 02/07/24 at 11:45 A.M., handwashing sink at the entrance to the kitchen area had leaking cold water. The hot water measured by the DS was 135.7 Fahrenheit (F) & 136.2 F degrees after 3 minutes of running the hot water. During an interview with dietary supervisor (DS) on 2/7/2024 at 11:45 A.M., the DS stated the cold-water faucet had been broken for over two weeks. The DS stated that she notified the maintenance supervisor (MS) about the problem two weeks ago. During an interview with the MS on 2/8/2024 at 10:13 A.M., the MS stated that he fixed the leak in the handwashing sink. The MS stated that he was notified on 2/7/2024 at 9:00 A.M. about the issue. The MS stated that he did not keep any paper records of repair requests from the kitchen, because he fixed the problem immediately. A review of the facility's Policy and Procedures (P&P) titled Sanitation and Infection Control dated revised 2019, indicated Handwashing 1. Before starting work in the kitchen. 2. After handling carts, soiled dishes, and utensils. 3. Before and after using cleaning products. 4. Before and after handling foods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 10 of 18 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 02/09/2024 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. 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 room(rooms 3,5,6,7,8,9,10,12,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45). Rooms 3,5 and 6 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 the residents and working space for the staff, which could affect the quality of life and safety for the residents. Findings: A review of the Request for Room Size Waiver letter submitted by the Administrator (ADM), dated 2/6/2024, 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 also 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 sq.ft. pr resident: Room # Room Size Floor Area #of beds 3 14.75'x10.6' 153 sq.ft. 2 5 14.5'x10.9 158 sq.ft. 2 6 14.5'x10.9' 158 sq. ft. 2 7 18.9 x 10.9' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 11 of 18 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 02/09/2024 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 206 sq.ft. Level of Harm - Potential for minimal harm 3 8 Residents Affected - Some 18.9'x10.9' 206 sq.ft. 3 9 18.9'x10.9' 206 sq.ft. 3 10 19' x 11.4' 217 sq. ft. 3 12 18.9'x10.9' 206 sq.ft. 3 15 18.9'x10.9' 206 sq.ft. 3 16 18.9'x10.9' 206 sq.ft. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 12 of 18 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 02/09/2024 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 17 18.9'x10.9' Residents Affected - Some 206 sq.ft. 3 18 18.9'x10.9' 206 sq.ft. 3 19 18.9'x10.9' 206 sq.ft. 3 20 18.9'x11.3' 213 sq.ft. 3 21 19.5'x11.1' 216 sq.ft. 3 22 18.9'x11.3' 213 sq.ft. 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 13 of 18 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 02/09/2024 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 23 Level of Harm - Potential for minimal harm 19.1'x10.8' 206 sq.ft. Residents Affected - Some 3 24 19.1'x10.8' 206 sq.ft. 3 25 19.1'x10.8' 206 sq.ft. 3 26 19.1' x 11.1' 210 sq.ft. 3 27 18.1'x11.1' 199 sq.ft. 3 28 19'x11' 209 sq.ft. 3 29 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 14 of 18 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 02/09/2024 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 19'x11' Level of Harm - Potential for minimal harm 209 sq.ft. 3 Residents Affected - Some 30 19.1x10.8' 206 sq. ft. 3 31 19'x11' 209 sq.ft. 3 32 19'x11' 209 sq.ft. 3 33 19'x11' 209 sq.ft. 3 34 19'x11.1' 210 sq.ft. 3 35 19'x11' 209 sq.ft. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 15 of 18 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 02/09/2024 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 36 19'x11' Residents Affected - Some 209 sq.ft. 3 37 19'x11' 209 sq.ft. 3 38 18.9'x10.8' 204 sq.ft. 3 39 18.9'x10.8' 204 sq.ft. 3 40 18.9'x10.8' 204 sq.ft. 3 41 18.9'x10.8' 204 sq.ft. 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 16 of 18 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 02/09/2024 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 42 Level of Harm - Potential for minimal harm 18.9'x10.8' 204 sq.ft. Residents Affected - Some 3 43 18.9'x10.8' 204 sq.ft. 3 44 19'x11.1' 210 sq.ft. 3 45 19'x11.1' 210 sq.ft. 3 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 bedroom is at least 240 sq. ft. During the recertification Survey on 2/9/2024, staff interviews indicated there were no concerns regarding the size of the rooms. During multiple observations of the resident's rooms from 2/6/2024-2/9/2024, 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 bedside tables, side tables and resident care equipment. During an interview on 2/9/2024 at 11:42 A.M., the ADM stated the facility submitted a written request for the continued room waiver although the room sizes do not impede resident care. During a concurrent observation and interview on 2/9/2024 at 11:47 A.M., with the maintenance supervisor (MS), the MS used a tape measurer to measure the size of the room from the window to the door for the length, then to measure the room from wall to wall horizontally for the width. The MS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 17 of 18 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 02/09/2024 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 stated, this is how I measure to verify the size of the rooms. Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 18 of 18