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Health Inspection Summary

Burlington Convalescent Hospital

845 S.Burlington Avenue

Los Angeles, CA 90057

(213) 381-5585

Deficiency Category	Inspection Date: 2/9/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 3/17/23 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 9/6/19 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	0	1	1
Quality of Life and Care Deficiencies	0	5	7
Infection Control Deficiencies	0	0	5
Resident Assessment and Care Planning Deficiencies	1	1	3
Nursing and Physician Services Deficiencies	0	1	2
Resident Rights Deficiencies	2	2	1
Nutrition and Dietary Deficiencies	1	1	1
Pharmacy Service Deficiencies	0	1	1
Environmental Deficiencies	2	2	1
Administration Deficiencies	1	0	0

Detailed result for inspection on 2/9/24

Date of last standard health inspection:	2/9/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	No complaint inspections
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	7
Average number of Health Deficiencies in California:	16.3
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
No Quality of Life and Care Deficiencies were found during this inspection period.

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Maintain 15 months of resident assessments in the resident's active clinical record.	2/9/24	3/1/24	2 - Minimal harm or potential for actual harm	Some

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
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.	2/9/24	3/1/24	2 - Minimal harm or potential for actual harm	Few
Reasonably accommodate the needs and preferences of each resident.	2/9/24	3/1/24	2 - Minimal harm or potential for actual harm	Some

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	2/9/24	3/1/24	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Keep all essential equipment working safely.	2/9/24	3/1/24	2 - Minimal harm or potential for actual harm	Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.	2/9/24	3/1/24	1 - Potential for minimal harm	Some

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
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.	2/9/24	3/1/24	2 - Minimal harm or potential for actual harm	Some

Detailed result for inspection on 3/17/23

Date of last standard health inspection:	3/17/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	12/21/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	14
Average number of Health Deficiencies in California:	17.3
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	3/17/23	4/10/23	2 - Minimal harm or potential for actual harm	Some

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	3/17/23	4/10/23	2 - Minimal harm or potential for actual harm	Some
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	3/17/23	4/10/23	2 - Minimal harm or potential for actual harm	Few
Provide or obtain dental services for each resident.	3/17/23	4/10/23	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	12/21/23	1/19/24	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	3/17/23	4/10/23	2 - Minimal harm or potential for actual harm	Some

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	3/17/23	4/10/23	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.	3/17/23	4/10/23	2 - Minimal harm or potential for actual harm	Few

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	3/17/23	4/10/23	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	3/17/23	4/10/23	2 - Minimal harm or potential for actual harm	Some

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.	3/17/23	4/10/23	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	3/17/23	4/10/23	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.	3/17/23	4/10/23	2 - Minimal harm or potential for actual harm	Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.	3/17/23	4/10/23	1 - Potential for minimal harm	Some

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 9/6/19

Date of last standard health inspection:	9/6/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	1/11/23Read the full report (PDF) 12/28/22Read the full report (PDF) 11/17/22Read the full report (PDF) 10/26/22Read the full report (PDF) 7/28/22Read the full report (PDF) 7/8/22Read the full report (PDF) 6/8/22Read the full report (PDF) 5/24/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	22
Average number of Health Deficiencies in California:	15.3
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	1/11/23	1/21/23	2 - Minimal harm or potential for actual harm	Some

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	9/6/19	10/8/19	2 - Minimal harm or potential for actual harm	Some
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	9/6/19	10/8/19	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	9/6/19	10/8/19	2 - Minimal harm or potential for actual harm	Few
Provide safe, appropriate dialysis care/services for a resident who requires such services.	9/6/19	10/8/19	2 - Minimal harm or potential for actual harm	Few
Provide safe, appropriate dialysis care/services for a resident who requires such services.	7/8/22	7/19/22	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	5/24/22	6/7/22	2 - Minimal harm or potential for actual harm	Few
Provide safe, appropriate pain management for a resident who requires such services.	9/6/19	10/8/19	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	12/28/22	1/9/23	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	7/28/22	8/15/22	2 - Minimal harm or potential for actual harm	Some
Provide and implement an infection prevention and control program.	9/6/19	10/8/19	2 - Minimal harm or potential for actual harm	Some
Provide and implement an infection prevention and control program.	10/26/22	11/11/22	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	6/8/22	6/24/22	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	9/6/19	10/8/19	2 - Minimal harm or potential for actual harm	Few
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.	9/6/19	10/8/19	1 - Potential for minimal harm	Some
Plan the resident's discharge to meet the resident's goals and needs.	9/6/19	10/8/19	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	6/8/22	6/28/22	2 - Minimal harm or potential for actual harm	Some
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	11/17/22	12/9/22	2 - Minimal harm or potential for actual harm	Some

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	9/6/19	10/8/19	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	9/6/19	10/8/19	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that residents are free from significant medication errors.	9/6/19	10/8/19	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	9/6/19	10/8/19	2 - Minimal harm or potential for actual harm	Some

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	12/21/23	1/19/24	2 - Minimal harm or potential for actual harm	Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	1/11/23	1/21/23	2 - Minimal harm or potential for actual harm	Some
Provide safe, appropriate dialysis care/services for a resident who requires such services.	7/8/22	7/19/22	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	5/24/22	6/7/22	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	12/28/22	1/9/23	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	7/28/22	8/15/22	2 - Minimal harm or potential for actual harm	Some
Provide and implement an infection prevention and control program.	10/26/22	11/11/22	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	6/8/22	6/24/22	2 - Minimal harm or potential for actual harm	Few
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	6/8/22	6/28/22	2 - Minimal harm or potential for actual harm	Some
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	11/17/22	12/9/22	2 - Minimal harm or potential for actual harm	Some

Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.

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