Inspection·June 12, 2025

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 the facility failed to maintain record that is complete and accurate for one of three sampled residents (Resident 1). For Resident 1 the facility failed to: Residents Affected - Few 1.Provide assistance with activities of daily living (ADLs) on 11/11/22. 2.Document nursing services that were provided to Resident 1 on 11/11/22 from 7 p.m. to 12:30 a.m. These deficient practices resulted in incomplete and inaccurate medical record for Resident 1. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 11/11/22 with diagnoses including respiratory failure (impaired gas exchange between the lungs (breathing organ) and the blood) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1's admission Assessment indicated the facility admitted Resident 1 on 11/11/22 at 7 p.m. The Assessment indicated Resident 1 was confused. Resident 1 was dependent with eating/nutrition, personal hygiene and grooming. Resident 1 was incontinent of bowel and bladder. During a concurrent interview and record review on 6/12/25 at 12:01 p.m., Resident 1's admission Assessment was reviewed the registered nurse supervisor (RNS 1). RNS 1 stated the facility admitted Resident 1 on 11/11/22 at 7 p.m. RNS 1 stated the nurses should make rounds at least every two to three hours, check on how Resident 1 was doing and make sure Resident 1 was okay . RNS 1 stated she was unable to find documentation that the nurses made their rounds. RNS 1 stated it is important to document what .we did for the patient (Resident 1). RNS 1 stated the documentation communicates how Resident 1 was doing during the shift. During a concurrent interview and record review, on 6/12/25 at 1:26 p.m., Resident 1's Documentation Survey Report (record of ADLs and assistance provided to residents) for 11/22 was reviewed with the director of staff development (DSD). DSD stated she was unable to find documentation that the certified nursing assistant (CNA) provided care to Resident 1. DSD stated even if Resident 1 was a new admit on 11/11/22, the CNA should do frequent rounds to find out how Resident 1 was doing. DSD stated the CNA should document what was done for the patient that included if Resident 1 had voided or was turned. During a review of the facility Policy titled Activities of Daily Living (ADLs), Supporting , (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056326 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 06/12/2025 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)