Health inspection·February 21, 2025

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few self-administration of medication, LVN 2 was unable to state the risks of leaving medications at Resident 58's bedside. During an interview on 2/21/2025 at 12:17 PM Director of Nursing (DON) stated Residents are only allowed for have Meds at bedside if they have been assessed to be cognitive and physically demonstrated they can safely able to do so and have a physician approval, DON stated medication at bedside should be in a locked container, DON further stated medications should not be left at bedside, because an confused wandering Resident may consume the medications which could lead to an adverse reactions, unnecessary hospitalization and possible poor outcomes, During record review, the facility's policy and procedures titled Self-Administration of Medication dated 03/2023 indicated, .the Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the Resident), assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the Resident. Self-administered medications are stored in a safe and secure place, which is not accessible by other Residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 2 of 23 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 02/21/2025 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete a change of condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) in accordance with the facility's policy and procedures (P&P) titled Change in a Residents Condition or status revised 3/2023 for one of four sampled residents (Resident 39). Residents Affected - Few This deficient practice had the potential to result in the delay of care for Resident 39. Findings: During record review, Resident 39's admission Record indicated the facility admitted Resident 39 on 6/12/2024 and readmitted Resident 39 on 9/9/2024 with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), personal history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) and cerebral vascular accident (CVA- Stroke) without residuals, and hypertension (HTN - elevated blood pressure). During record review Resident 39's Weight Summary indicated the following weights: 10/29/2024 : 105.0 pounds (lbs -unit of measure) 10/15/2024: 104.0 lbs 10/8/2024: 104.0 lbs 10/4/2024: 104.0 lbs 9/9/2024: 114.0 lbs During record review, the Nutrition/Dietary note dated 10/4/2024, at 4:19 P.M., indicated Resident 39 lost 10 lbs weight loss related to wounds, recent hospitalization, fluid shifts, advanced age, variable by mouth intake, mechanically altered diet . unavoidable. During record review, Resident 39's Minimum Data Set (MDS - a resident assessment tool) dated 12/16/2024, indicated Resident 39 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 39 required extensive staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent interview and record review, on 2/20/2025, at 12:45 P.M., with Minimum Data (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 3 of 23 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 02/21/2025 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 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set/ Registered Nurse Supervisor (MDS/RNS), Resident 39's electronic chart was reviewed. MDS/RNS stated Resident 39 had lost a total of 10 lbs between 9/9/2024 and 10/4/2024. MDS/RNS stated facility should have done a COC of the weight loss, however, there is no documented evidence that a COC was done. Weight loss is a change in condition that needs to be monitored, physician needs to be notified as well as family member or representative so that the resident should not lose more weight, get weak and have an overall decline in ADL. During an interview on 2/21/2025, at 7:27 A.M., the Director of Nursing (DON) stated, a COC is a deviation from the resident's baseline and should be done as soon as the deviation is noted. DON stated the COC for weight loss is done to alert everyone, licensed nurses, certified nursing assistants, all the departments including the doctor and family that there was a change in the resident's condition that needs to be monitored and if the COC is not done, the doctor may not know what is happening to the resident and the right interventions will not be applied. During record review, the facility's P&P, titled, Change in a Residents Condition or status revised 3/2023, indicated, Policy statement: Our facility promptly notifies the resident, his or her attending physician, and the resident's representative of changes in the residents medical/mental condition and/or status. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 4 of 23 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 02/21/2025 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. Based on interview and record review, the facility failed to develop a baseline care plan in accordance with the facility's policy and procedures (P&P) titled Care plans, Comprehensive Person-Centered revised 3/2023 for one of four sampled residents (Resident 39). These deficient practices had the potential to negatively affect the delivery of necessary care and services for Resident 39. Findings: During record review, Resident 39's admission Record indicated the facility admitted Resident 39 on 6/12/2024 and readmitted Resident 39 0n 9/9/2024 with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), personal history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) and cerebral vascular accident (CVA- Stroke) without residuals, and hypertension (HTN - elevated blood pressure). During record review, Resident 39's Minimum Data Set (MDS - a resident assessment tool) dated 12/16/2024, indicated Resident 39 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 39 required extensive staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent interview and record review, on 2/20/2025, at 12:45 P.M., with Minimum data set coordinator/Registered Nurse Supervisor (MDS/RNS), Resident 39's electronic chart was reviewed. The MDS/RNS stated a care plan is a tool for staff to know what they are supposed to be doing and follow the approach and interventions for that resident in order to meet the goals for the resident. The MDS/RNS stated Resident 39's weight loss should have been care planned, however, there is no documented evidence of a care plan. The MDS/RNS further stated without a care plan, facility staff will not have a guide on what to do for Resident 39 which might lead to her losing more weight. During an interview, on 2/21/2025, at 7:27 A.M., with the Director of Nursing (DON), the DON stated a care plan is done to solve, minimize or alleviate a problem that have been identified, care plans should be done as soon as the problem has been identified and if Resident 39's care plan for weight loss is not done, it can cause the resident to loose more weight, a decline in function and increased weakness. During record review, the facility's P&P, titled, Care plans, Comprehensive Person-Centered revised 3/2023, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for reach resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or significant change in status), and no more than 21 days after admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 5 of 23 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 02/21/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 activities of daily living (ADL-such as bathing, showering, toileting, and mobility) for one of four residents (Residents 14) Residents Affected - Few This failure had the potential to result in Resident 14 acquiring infection, and foul odor of the feet. Findings: During record review, Resident 14's admission Record indicated the resident was re-admitted to the facility on [DATE] with diagnoses not limited to hemiplegia (complete paralysis on one side of the body), hemiparesis (weakness or reduced movement on one side of the body), and anemia (a condition in which the body does not have enough healthy red blood cells). During record review, resident 96's Minimum Data Set (MDS- a resident assessment tool) dated 11/25/24, indicated Resident 14's cognitive skills- (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making was not intact. The MDS further indicated Resident 14 needed extensive assistance with ADL's (bathing, showering, and toileting), and moderate assistance with dressing. During an observation on 2/18/25 at10:26 am, Resident 14 was observed sitting in a wheelchair (WC). Resoident 14's shoes had dark stains on the white portion of the shoes, grime, and were dusty. Certified Nursing Assistant (CNA) 1 put the shoes on Resident 14's feet and then wheeled the resident to the activity room. During an interview on 2/18/25 at 10:26 am, CNA 1 stated she does not know the last time she had in-service on ADL care. CNA 1 stated the nurses are supposed to clean the resident's shoes or send them to the laundry to be washed. CNA stated Resident 14's, dirty shoes is a hygiene and infection control issue. CNA 1 stated that Resident 14 can get a fungal foot infection, a rash, or have a foul odor to both feet. During an observation and interview on 2/18/25 at 10:56 am the Activities Director was observed bringing/wheeling Resident 14 back to the resident's room to change the resident's dirty shoes. The Activities Director stated she brought Resident 14 back to the resident's room to change his shoes because the shoes were very dirty. The Activities Director stated the nurses are not supposed to put the resident on dirty shoes. The Activities Director stated the nurses are supposed make sure all the residents are clean and well-groomed before the residents leave their room. The Activities Director stated the Resident 14 could get a foot infection by wearing dirty shoes. During an interview on 2/18/25 at 11:29 am, with Licensed Vocational Nurse (LVN) 2 for Resident 14. LVN 2 stated the residents should always wear clean clothes and shoes. LVN 2 stated if the residents wear dirty shoes, they can have foul odor, get a bad rash, or get a fungal infection to their feet. During record review, the facility document titled Activities of Daily Living (ADL's), Supporting revised on 3/2023, indicated, Residents will be provided with care, treatment and services to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 6 of 23 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 02/21/2025 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 0677 to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 7 of 23 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 02/21/2025 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise/update fall care plan to include updated interventions after the fall on 12/28/2024 to prevent a repeat fall for one of two residents (Resident 165) who was a high risk for fall. As a result, on 2/3/25, Resident 165 fell again and suffered severe pain of 7 (seven) out of 10 (7/10 - a numerical pain scale assessment tool where zero is no pain and 10 is severe pain) to the buttocks and to the left and right thighs. On 2/5/2025, the facility transferred Resident 165 to General Acute Care Hospital (GACH) 1 via non-emergency medical transportation where Resident 165 was diagnosed with a left hip fracture (broken bone). On 2/16/25, GACH 1 performed an open reduction and internal fixation (ORIF - a type of surgery used to stabilize and repair broken bones, using screws, plates, sutures, or rods to hold the bone together and for healing) on Resident 165. Findings: During a record review, Resident 165's admission Record indicated the facility admitted the resident on 10/2/2019 with diagnoses including dementia (a progressive state of decline in mental abilities), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and a history of falling. During a record review, Resident 165's at risk for falls care plan, initiated on 10/17/2019 and reviewed on 1/7/2025, indicated the resident was at risk for falls due to the resident's diagnosis of dementia, being unaware of safety and poor judgment. The care plan indicated the goal included to reduce the resident's risk of falls and injury. The care plan interventions indicated staff to: - Visibly observe resident frequently. - Encourage the resident to attend and participate in activity programs; and - Provide safety instruction to resident regarding ambulation, transfers, and ADLs when appropriate. Bilateral 1/3 side rails (a barrier on the side of the bed that prevents one from falling out of bed) up and grab bars (bars are safety devices designed to enable a person to maintain balance, lessen fatigue while standing), walker. The care plan indicated all interventions were initiated on 10/18/2019. During a record review, Resident 165's care plan titled, Resident is at risk for spontaneous/ pathological (a break in the bone caused by a disease and not an injury)/ stress fracture (a small crack in the bone caused by placing too much stress on the bone), initiated on 2/22/2022 and reviewed on 1/7/2025, indicated the resident was at risk for fracture due to related to dx of osteoarthritis. The care plan goal included to reduce the risk of fracture and injury to Resident 1. The care plan interventions indicated to: - Perform x-ray as indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 8 of 23 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 02/21/2025 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 - Provide a safe and hazard free environment Level of Harm - Actual harm - Assist with all transfers and ambulation as needed Residents Affected - Few - Facility POP (Protect Our Patients from Pathological Fracture) program -Fall risk interdisciplinary team (IDT - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) conference. The care plan interventions were not updated since 2/22/2022. During a record review, Resident 165's History and Physical (H&P), dated 11/13/2024, indicated Resident 165 did not have the capacity to understand and make decisions. During a record review, Resident 165's Change of Condition (COC- clinically important deviation from a patient's baseline) form, dated 12/28/2024, indicated Resident 165 was observed sitting on the floor on the left side by the housekeeping staff and the charge nurse (Licensed Vocational Nurse - LVN) in the smoking patio. The COC indicated the resident reported to Registered Nurse (RN) 1 that he was walking towards the resident's chair to sit down when he [Resident 165] fell. The COC indicated that per Resident 165, the resident landed on the butt and back and did not have pain or discomfort. The COC further indicated Resident 165 was noted with same shuffling gate pattern. During a record review, Resident 165's Quarterly Minimum Data Set (MDS- a resident assessment tool) dated 1/2/2025, indicated the resident's cognition (ability to think, understand, and reason) was moderately impaired. The MDS indicated Resident 165 required supervision or touch assistance (helper provides verbal cues and /or touching/steadying as the resident completes the activity) with oral hygiene, upper body dressing and toileting hygiene. The MDS also indicated Resident 165 uses a walker for mobility and required supervision or touching with walking 10 feet, 50 feet and 150 feet. The MDS further indicated Resident 165 had one prior fall since the last MDS assessment (assessments are completed every 3 months. [Date not indicated.]) During a record review, Resident 165's Fall Risk assessment dated [DATE] (one month prior to the 2/3/2025 fall), indicated Resident 165 scored 22 (high risk for falls). During a record review, Resident 165's COC form, dated 2/3/2025 (37 days after the 12/28/24 fall), indicated Resident 165 was observed sitting on the smoking patio floor. Resident 165 complained of pain to the buttocks and both thighs. The COC also indicated the resident reported a 7/10 pain level with movement and the physician ordered a stat (immediate) x-ray of both hips. During a record review, Resident 165's Radiology Results Report (from the facility), dated 2/4/2025, indicated Resident 165 had x-ray of both hips. The x-ray report indicated Resident 165 had an intertrochanteric left femoral fracture (left thigh bone break). During a record review, Resident 165's COC form, dated 2/4/2025, indicated the x-ray results indicated Resident 165 had left thigh fracture. The COC further indicated a physician ordered to transfer the resident to GACH. During record review, Resident 165's Physician Order, dated 2/4/2025, indicated the facility to transfer Resident 165 to GACH 1 for evaluation of acute intertrochanteric left femoral fracture sustained after a fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 9 of 23 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 02/21/2025 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 During a record review Resident 165's Progress Note, dated 2/5/2025, indicated the resident was transferred to GACH 1 via non-emergency medical transportation. Level of Harm - Actual harm Residents Affected - Few During a record review, Resident 1's GACH 1's Emergency Department (ED) Medical Doctor (MD) Note, dated 2/5/2025, indicated Resident 165 presented to the ED after falling while trying to smoke. The ED MD note also indicated Resident 165 complained of left arm and hip pain and received Morphine (an opioid pain medication) 2 milligrams (mg - unit of measurement) intravenously (IV -inside a vein) for pain control (pain level not indicated). The ED MD note further indicated Resident 165's x-ray showed a comminuted (where the bone breaks in two or three places) left hip fracture. During a record review, Resident 165's Orthopedic (branch of medicine that focuses on the diagnosis and treatment of bones, muscles, and ligaments) Surgical Consultation Report, dated 2/5/25, indicated the resident came to the GACH complaining of pain involving the left hip, which developed following a ground level fall landing on the left hip. The Orthopedic Surgical Consultation Report also indicated there was tenderness and swelling around the left hip and that Resident 165 experienced pain when attempting range of motion (ROM - the extent to which a joint in the body can move) to the left hip. The Orthopedic Surgical Consultation Report further indicated the x-ray of the left him revealed a comminuted unstable left hip fracture. During a record review, Resident 165's GACH 1 Operative Report, dated 2/16/2025, indicated Resident 165 had an ORIF surgery on 2/16/2025 to treat the resident's left femoral fracture. During a concurrent interview and record review 2/20/2025 at 10:18 AM with Registered Nurse Supervisor (RN) 1, Resident 165's electronic health records were reviewed. While reviewing Resident 165's COC form dated 2/3/2025, RN 1 stated that Resident 165 was found sitting on the ground on the smoking patio. RN 1 stated whenever a resident is found on the floor, the resident is considered to have fallen. RN 1 stated Resident 165 complained of pain when found on the patio floor and was administered Tylenol (pain medication). RN 1 stated Resident 165 had slight pain relief. RN 1 further stated that on 12/28/2024, Resident 165 previously fell when RN 1 was on duty and that the resident did not have any injuries. During a concurrent review of Resident 1's care plans, RN 1 stated RN 1 did not update Resident 165's fall care plan after the fall on 12/28/2024. Also, RN 1 stated that RN 1 did not create a new care plan that addressed the resident falling. RN 1 stated the fall care plan should have been updated to prevent the resident from falling again. RN 1 further stated an updated care plan should address the resident's needs and may have prevented the resident from falling and breaking his bone. During a concurrent interview and record review with the Director of Nursing (DON) on 2/21/2025 at 10:40 AM, Resident 165's care plans and COCs were reviewed. The DON stated Resident 165 had two recent falls. The DON stated after Resident 165 last fell on 2/3/2025, the resident was transferred to a GACH and was diagnosed with a left hip fracture. Upon reviewing Resident 165's care plans, the DON stated Resident 165's care plan interventions to prevent falling were not updated after the resident fell on [DATE]. The DON stated Resident 165's risk for fall care plan interventions were not updated after 10/18/2019. The DON further stated the care plan addresses the resident's identified problems and contains interventions to prevent or minimize the risk to residents. The DON further indicated staff update the care plan when new issues arise or and the care should have been updated after the 12/28/24 fall to prevent or minimize the risk of Resident 165 falling again. During a record review, the facility's policy, and procedures (P&P) titled, Safety and Supervision of Residents, revised 7/2017, indicated, resident safety and supervision and assistance to prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 10 of 23 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 02/21/2025 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 Level of Harm - Actual harm Residents Affected - Few accidents are facility-wide priorities. The P&P also indicated, monitoring the effectiveness of interventions shall include evaluating the effectiveness of interventions, modifying or replacing interventions as needed and evaluating the effectiveness of new or revised interventions. During a record review, the facility's P&P titled, Falls - Clinical Protocol, revised 3/2018, indicated, while many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. For an individual who has fallen, the staff will begin to try to identify possible causes within 24 hours of the fall. Often, multiple factors contribute to a falling problem. The P&P also indicated, The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. The P&P further indicated, based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. During a record review, the facility's P&P titled, Care Plans, Comprehensive Person-Centered, reviewed 3/2023, indicated, a comprehensive care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was to be developed and implemented for each resident. The care planning process will include an assessment of the resident's strengths and needs, incorporate the resident's personal and cultural preferences in developing the goals of care. The P&P further indicated, assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 11 of 23 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 02/21/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that staff did not crush Ferrous Sulfate (supplement) Oral (by mouth) tablet 325 (65 Fe) mg 1 tablet by mouth and administered via gastrointestinal tube (G-tube -feeding tube surgically inserted into the stomach). for one of four sampled residents (Resident 315). Residents Affected - Few This deficient practice: 1. Resulted in staff crushing and administering Ferrous Sulfate Oral tablet 325 mg 1 tablet via GT for six days. 2. Had the potential to result in increasing the risks of side effects, toxic effects and/or hospitalization. Findings: During record review, Resident 315's admission Record indicated the facility admitted Resident 315 on 6/9/2023, and readmitted Resident 315 on 2/12/2025 with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), and adult failure to thrive (a noticeable decline in health). During record review, the physician's orders dated 2/12/2025 and 2/13/2025, indicated Ferrous sulfate (mineral used to increase iron level in the blood) oral tablet 325 (65 Fe [iron]) milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), give 1 tablet via G-tube. During record review, Resident 315's Minimum Data Set (MDS - a resident assessment tool) dated 2/19/2024, indicated Resident 315 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 315 required extensive staff assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During record review, the Medication Administration Record (MAR) for 2/2025, indicated Ferrous Sulfate Oral tablet 325 (65 Fe) mg give 1 tablet by mouth via G-tube one time a day for supplement. The MAR further indicated there were check marks with staff initials that indicated Ferrous Sulfate 325 mg tablet was administered via GT to Resident 315 on 2/13/2025, 2/14/2025, 2/15/2025, 2/16/2025, 2/17/2025, and 2/18/2025. During a concurrent observation and interview on 2/19/2025, at 8:50 A.M., Licensed Vocation Nurse (LVN) 2 dispensed a ferrous sulfate tablet 325 mg 1 tablet (red in color with a shiny coating), placed the tablet in a pill crushing pouch. LVN 2 then crushed the ferrous sulfate tablet and placed the crushed ferrous sulfate tablet in a medication dispenser cup. LVN 2 then donned personal protective equipment (PPE- [gown, gloves, masks .]). LVN 2 then added water to the crushed ferrous sulfate tablet, connected feeding g-tube syringe to the g-tube and the surveyor/writer stopped LVN 2 just before LVN 2 was about to pour the ferrous sulfate mixed with water into the g-tube syringe. LVN 2 stated that the ferrous sulfate tablet was coated, should not be crushed because it needs to be given time to dissolve to protect the stomach and if crushed can cause stomachache. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 12 of 23 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 02/21/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 2/21/2025, at 7:17 A.M., with the Director of Nursing (DON), a picture of the ferrous sulfate tablets was observed. The DON stated, the ferrous sulfate tablet is red, shiny, and appeared to have a coating on it. The coating on the tablet is there to protect the stomach wall by slowly releasing the tablet. The DON stated if the coated tablet is crushed before consumption, it creates a fast absorption of the tablet, cause harm to the stomach, causing stomachache, nausea, and uneasiness to the resident. During record review, the facility's policy and procedures, titled, Preparation and general guidelines effective 10/2017, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices . a. Long acting or enteric coated dosage forms should generally not be crushed; an alternative should be sought. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 13 of 23 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 02/21/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During an observation and concurrent interview on 2/20/2025 at 12:49 PM, the facility served a test tray to State Agency (SA). The test tray consisted of rice mixed with red kidney beans, roast beef, carrots, and a brownie, and not appealing. Dietary Supervisor (DS) used a thermometer to tested the temperature of the roast beef. The roast beef temperature registered at 127 degrees Fahrenheit (F - a scale for measuring temperature). SA tasted the food from the test tray but barely ate any of the test tray food. SA tested the food and stated that the roast beef was hard to chew and did not have any flavor, the carrots were not palatable or tender, the red beans and rice was mushy and salty, the temperature was okay, but the portions were small. Residents Affected - Some During record review, the facility policy and procedures titled Food and Nutrition Services revised 10/2017, indicated, 7. the food appears palatable and attractive, and it is served at a safe and appetizing lempe.rature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. b. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded. b. During record review, Resident 58's admission Record indicated Resident 58 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation (an irregular and often very rapid heart rhythm), hypertension (a medical condition characterized by persistently elevated blood pressure), encephalopathy (a change in your brain function due to injury or disease), rhabdomyolysis ( a breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream.), and acute kidney failure (a condition in which kidneys suddenly stop working, causing a buildup of waste and fluid in the body). During record review, Resident 58's Minimum Data Set (MDS - a resident assessment tool) dated 01/3/2025, indicated the Resident 58's cognition (The mental ability to make decision of daily living) was intact, Resident 53's required setup for eating, upper body dressing and taking off foot wear, supervision for oral hygiene, toileting hygiene and lower body dressing, Resident 58 required partial/moderate assistance with shower/bathing and personal hygiene. During record review, Resident 58's History and Physical (H&P) dated 1/6/2025, indicated Resident 58 did not have the capacity to understand and make decisions. During a facility tour and concurrent interview on 2/18/2025 at 11:50 AM, Resident 58 stated, lunch and dinner meals taste awful. Resident 58 stated he does not eat the food most of the time because the food looks like dog food and had lost a significant amount of weight since admission to the facility. During record review, Resident 58's electronic health record (EHR) indicated Resident 58 had lost 8 pounds (lbs-unit of measurement) in 2 months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 14 of 23 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 02/21/2025 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During record review, the facility policy and procedures titled Food and Nutrition Services revised 10/2017, indicated, 7. the food appears palatable and attractive, and it is served at a safe and appetizing lempe.rature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. b. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded. Based on observation, interview, and record review, the facility failed to ensure residents received meals with flavor, attractive, appetizing, nutritive value, proper temperature, safe, and adequate portions. This deficient practice had the potential for the residents to experience poor/reduced meal intake, weight loss, and a decline in their health status. Findings: a. During a record review, the Resident Council Meeting minutes 11/13/2024 at 2 PM, a resident complained that the, Rice is not cook enough and can't digest it. During Resident Council Meeting on 2/19/2025 at 10:50 AM, four residents (Residents 40, 45, 62, and 65) were present. Resident 62 stated the facility give so little food and we eat cold soup. Resident 40 stated, the sandwich has cheese, and no meat. Resident 65 stated the sandwich has two breads and a cheese, no meat, nothing more. I didn't like the food. The food is not enough. Resident 45 stated that, the food food was cold when it's supposed to be hot. During record review, the facility policy and procedures titled Food and Nutrition Services revised 10/2017, indicated, 7. the food appears palatable and attractive, and it is served at a safe and appetizing lempe.rature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. b. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded. During record review, the facility policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Food Preparation and Service revised in 2022, indicated, Potentially harzadous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt, . When food is left in the danger zone (temperatures between 41-135 degrees F) for more than four hours rapid growth of pathogenic microorganisms (organisms that can cause disease) can cause foodborne illness (a disease or infection caused by consuming contaminated food). The P&P did not address palatability (quality of food being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 15 of 23 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 02/21/2025 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 0804 tasty) of the food served to residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 16 of 23 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 02/21/2025 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 storage and food preparation practices in the kitchen by failing to ensure that: Residents Affected - Some 1. Kitchen staff are trained and competent in food cooling down method 2. Cooked left over chicken and ground beef are not stored in the refrigerator 3. Kitchen staff recorded and retained documented evidence of the cooling down food/meat following the cooling down method. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses and other toxins) medically compromised residents who received food from the kitchen. Findings: During the initial tour and observation of the kitchen on 02/18/2025 at 7:29 am, with Tray line staff, the kitchen refrigerator had a container of cooked chicken and ground beef. During a concurrent interview, the Tray line staff he stated the cooks are not supposed to store cooked food in the refrigerator at any time. During an interview with Dietary Cook, Dietary [NAME] stated that she cooked the ground beef on 2-17-25. Dietary [NAME] stated she does not know the cooling down method for food/meats. Dietary [NAME] stated, if cooked food is not stored properly the residents could get very sick or have a stomachache. During an interview with on 02/18/25 at 11 am, Dietary Supervisor stated kitchen staff is not supposed to store cooked chicken and ground beef in the refrigerator. Dietary Supervisor stated the dietary department does not have a cooling down process for food/meats because the cooks are not supposed to keep cooked food in the refrigerator. Dietary Supervisor stated the cooks prepares and cooks fresh food for every meal. Dietary Supervisor stated, if food is not stored properly the residents could get salmonella (bacteria that causes diarrhea, fever and stomach pains) and sickness to the residents. During record review, the facility policy and procedures titled Safe Cooling Method dated12/18/2024, indicated, Policy: All cooked food not prepared for immediate use will be cooled properly to keep bacteria form developing. A. 6-hour or two stage method. 2. A cooling log will be maintained to ensure standards are met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 17 of 23 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 02/21/2025 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation and record review, the facility failed to provide a refrigerator to store food brought in for the residents. Residents Affected - Some This deficient practice had the potential to cause food borne illness due to the residents not having a refrigerator to store their food. Findings: During record review, the Facility Listing Report dated 2/18/2025, indicated the resident census was 111. During an observation and interview on 2/20/25 02:41 pm with the Registered Dietician, the Registered Dietician stated that the facility does not have a refrigerator for the residents to store food brought in from outside the facility. Registered Dietician stated she recommends that the residents and the residents family members to not bring in food that needs refrigeration. Registered Dietician stated it is the residents right to have food bought in by their families. During record review, the facility policy and procedures titled Food From Outside Sources indicated, Policy: Food brought to the facility by visitors and family is permitted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 18 of 23 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 02/21/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, facility failed to accurately and completely document medication administration in the resident's chart for one of four sampled residents (Resident 39). Residents Affected - Few This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 39. Findings: During record review, Resident 39's admission Record indicated the facility admitted Resident 39 on 6/12/2024 and readmitted Resident 39 on 9/9/2024 with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), personal history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) and cerebral vascular accident (CVA- Stroke) without residuals, and hypertension (HTN - elevated blood pressure). During record review, Resident 39's Minimum Data Set (MDS - a resident assessment tool) dated 12/16/2024, indicated Resident 39 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 39 required extensive staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During record review, Resident 39's change of condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) dated 9/3/2024, at 8:15 A.M., indicated Registered Nurse Supervisor (RNS) documented that on 9/3/2023 at 7:30 A.M., Resident 39 was having on and off abdominal pain and had been taking Pepto bismuth for gastric pain, Zofran (medication) for nausea and vomiting. During an interview on 2/18/2024, at 11:06 A.M., Resident 39 stated she (Resident 39) was having abdominal pain, and that facility staff gave her pain medication with no relief and therefore the resident was transferred to a general acute care hospital (GACH). During a concurrent interview and record review on 2/20/2024, at 12:20 P.M., with the Minimum Data Set Coordinator/Registered Nurse Supervisor (MDS/RNS), Resident 39's COC, physicians' orders, and medication administration records (MAR) were reviewed. The MDS/RNS stated that COC done on 9/3/2024 indicated that Resident 39 reported to have had on and off abdominal pain, dizziness, and that the resident was administered Pepto bismuth and Zofran. However, the MDS/RNS stated that there was not documented evidence that Pepto bismuth and or Zofran were administered to Resident 39 because the MAR was blank. The MDS/RNS stated Resident 39's pain assessment level was documented as 0 meaning no pain even though the COC stated resident 39 was having abdominal pain. During an interview on 2/21/2025, at 7:27 A.M., the Director of Nursing (DON) stated that documentation is done to show what happened and what was done for the resident. The DON stated medication administration documentation should be done right after the medication has been administered to communicate with other team members what it was done, and if not documented then it was not done. During record review, the facility's policy and procedures, titled, Charting and Documentation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 19 of 23 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 02/21/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm revised 7/2017, indicated, that all services provided to the resident, progress toward the care plan goals, or any changes in the residents medical, physical, functional, or psychosocial condition, shall be documented in the residents' medical records. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Residents Affected - Few 2. The following information is to be documented in the resident's medical record: . b. Medications administered: . e. Events, incidents or accidents involving the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 20 of 23 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 02/21/2025 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: During record review, the Request for Room Size Waiver letter submitted by the Administrator (ADM), dated 2/18/2025, 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' 206 sq.ft. 3 8 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. 3 17 18.9'x10.9' 206 sq.ft. 3 18 18.9'x10.9' 206 sq.ft. 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 21 of 23 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 02/21/2025 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 18.9'x10.9' 206 sq.ft. 3 Level of Harm - Potential for minimal harm 20 18.9'x11.3' 213 sq.ft. 3 21 19.5'x11.1' 216 sq.ft. 3 Residents Affected - Some 22 18.9'x11.3' 213 sq.ft. 3 23 19.1'x10.8' 206 sq.ft. 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 19'x11' 209 sq.ft. 3 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. 3 36 19'x11' 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 42 18.9'x10.8' 204 sq.ft. 3 43 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 22 of 23 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 02/21/2025 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 44 19'x11.1' 210 sq.ft. 3 Level of Harm - Potential for minimal harm 45 19'x11.1' 210 sq.ft. 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 bedroom is at least 240 sq. ft. During the recertification Survey on 2/18/2024, staff interviews indicated there were no concerns regarding the size of the rooms. During multiple observations of the resident's rooms on 2/18/2024-2/21/2024, 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 2/18/2024 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 2/19/2024 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 stated, this is how I measure to verify the size of the rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056326 If continuation sheet Page 23 of 23