Health inspection·December 7, 2023

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The surveyor removed the IJ on [DATE] at 4:10 pm in the presence of the ADM, the Director of Nursing (DON), and the Quality Assurance Consultant (QAC). The IJ Removal Plan, dated [DATE] included the following: a. On [DATE], the DON gave in-services and educated the facility ' s staff (in general) on indications for CPR and the importance of performing CPR immediately to residents who required CPR until the paramedics took over. The in-services included: calling for assistance, activating the facility ' s emergency response system by paging Code Blue (an emergency code that used to indicate a patient/resident requiring immediate cardiopulmonary resuscitation), retrieving the emergency cart [a cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate (to revive from apparent death or from unconsciousness) a patient experiencing cardiac arrest], initiating CPR, and continuing CPR until relieved by the paramedics or when the resident (in general) demonstrated obvious signs of life. b. On [DATE], the ADM contacted a certified Basic Life Support (BLS, certified to teach adult and child CPR, automated external defibrillator [AED, delivers an electric shock through the chest to the heart when it detected an abnormal rhythm and changed the rhythm back to normal], and First Aid classes) instructor to provide CPR reeducation to nursing staff including all CNAs, LVNs, and Registered Nurses (RN)s. c. On [DATE], the facility checked CPR certification cards for all nursing staff and identified eight of 61 CNAs and three of 35 LVNs did not have current CPR certification cards. d. On [DATE], the DON and the RNS 3 identified 87 of 123 residents had full code status. e. On [DATE], the certified BLS instructor conducted CPR training to nursing staff. f. On [DATE], CNA 2, LVN 1, and RNS 1 attended the CPR training provided by the certified BLS instructor. The facility scheduled a one-to-one CPR training for CNA 1 as soon as CNA 1 was available to attend (unspecified date). g. On [DATE], after the CPR classes were completed, the facility checked CPR certification cards (successfully completion of a designated first aid course in an authorized hospital, health, or training organization) for all 110-nursing staff and identified four of 61 CNAs (CNA 1, CNA 7, CNA 10, and CNA 12) did not have a current CPR card. h. On [DATE], the four CNAs without a current CPR card, which included CNA 1, were removed from the work schedule (include the hours of a day and the days of a work week that an employee is required to work) until the CNAs attended the next CPR training scheduled on [DATE]. i. On [DATE], the Assistant Director of Nursing (ADON) and the Social Services Director (SSD) updated the code status for all 123 residents and posted the list in each medication cart (MC, used to transport medications from patient room to patient room) for easy identification of code statuses. j. The DON and/or designee will conduct Mock Codes (pretend emergency situations in which a pretend patient has no pulse and/or not breathing and had to be provided CPR) twice a year and as needed. k. The Assistant Director of Staff Development (ADSD) would check CPR certification cards for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 2 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few employees upon hire, yearly, and as needed to ensure employees had their current CPR cards. Any nursing staff without a current CPR certification card would be removed from the work schedule until their CPR certification cards was renewed. Cross reference F726 Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility initially admitted Resident 1 to the facility on [DATE] and readmitted Resident 1 on [DATE] with diagnoses which included end stage renal disease (ESRD, a medical condition in which a person ' s kidneys permanently stop working and can no longer clean waste products from the blood and send waste products out of the body in urine). During a review of Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner, or a physician assistant which specifies what a patient ' s lifesaving treatment wishes are), dated [DATE], the POLST indicated Resident 1 had full code status and wanted all lifesaving procedures to be provided to Resident 1 if Resident 1 ' s heart stopped and/or if Resident 1 stopped breathing. During a review of Resident 1 ' s History and Physical (H&P, physician ' s clinical evaluation and examination of the resident), dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], the MDS indicated Resident 1 required touching or steadying assistance with toileting, dressing and personal hygiene (includes combing hair, shaving, washing/drying face and hands). The MDS also indicated Resident 1 required partial assistance to transfer to and from bed to chair/wheelchair, and to get on and off a toilet. During a review of Resident 1 ' s EMTs run report (a standard document used by emergency medical service care providers), dated [DATE] and timed 5:59 am, the report indicated EMTs arrived at the facility on [DATE] at 6:07 am and was at Resident 1 ' s bedside to evaluate Resident 1 at 6:08 am. The report indicated the EMTs found Resident 1 in bed, unresponsive and pulseless (without a pulse), and the EMTs started CPR on Resident 1 on [DATE] at 6:10 am. The report indicated Resident 1 ' s first monitored heart rhythm (electrical activity of the heart seen on a screen) was asystole (no heartbeat) and Resident 1 remained with no heartbeat after 20 minutes of CPR. The report indicated the time of Resident 1 ' s death was [DATE] at 6:30 am. During a review of Resident 1 ' s Situation, Background, Appearance, Review (SBAR, a standardized communication tool between healthcare providers) form signed by LVN 1, dated [DATE] and timed 6:30 am, the SBAR indicated Resident 1 had a change of condition identified on [DATE] at 5:55 am. The SBAR indicated Resident fell, had a change in level of consciousness (LOC, a medical term that describes a person ' s stated of awareness, alertness, and wakefulness), and had full code status with a blood oxygen level of zero (0, healthy blood oxygen level is 75–100 millimeters of mercury [mm Hg, unit of pressure] or 95–100 percent [%, number of ratio expressed as a fraction of 100]). The SBAR indicated Resident 1 fell, had a change in level of consciousness (LOC, a medical term that describes a person ' s stated of awareness, alertness, and wakefulness), and had full code status. The SBAR indicated at 5:55 am, CNA 1 reported to RNS 1 Resident 1 was on the floor. Resident 1 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 3 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few assessed by RNS 1, noted unresponsive, with initial vital signs of: blood pressure (BP, ideal BP is considered to be between 90/60 mm Hg, unit of and 120/80mmHg) of 46/26 mmHg, pulse at 39 (normal resting heart rate is from 60 to 100 beats per minute [BPM]), blood sugar at 222 milligrams per deciliter (mg/dl – units of measurement, normal fasting blood glucose concentration are between 70 mg/dL and 100 mg/dL). The SBAR indicated RNS 1 rechecked Resident 1 ' s vital signs (heart rate/HR, respiration rate/RR and BP) and Resident 1 had no pulse or zero (0 breaths per minute, normal RR for adults at rest is 12 to 18 breaths per minute) signs of breathing noted. The SBAR indicated CPR was initiated (unspecified person), 911 (emergency number for police, fire, paramedics) was called and the paramedics arrived at 6:07 am. The SBAR indicated the paramedics took over care, however, Resident 1 was unable to be revived (restore to life or consciousness) and pronounced dead by the paramedics at 6:30 am. During a review of Resident 1 ' s Licensed Nursing Note written by RNS 1, dated [DATE] and timed 6:50 am, the Nursing Note indicated at 5:55 am, (nurse assigned to Resident 1, CNA 1) reported to supervisor (RNS 1) that resident was on the floor. The note indicated RNS 1 got to Resident 1 ' s room immediately and Resident 1 was on the floor. The note indicated RNS 1 assessed Resident 1, pat Resident 1 ' s shoulder, but Resident 1 was not responsive (state of being responsive). The note indicated Resident 1 ' s pulse can hardly be appreciated (palpable, felt by touch) by RNS 1 and rise and fall (describes the physical action of breathing) of Resident 1 ' s chest was absent. The note indicated Resident 1 ' s BP was 46/26 mm Hg, the HR was 39 BPM. The note indicated (unspecified person) started CPR, called 911, the paramedics arrived at 6:07 am and took over care. The noted indicated the paramedic started IV (intravenous line - a soft, flexible tube placed inside a vein, usually in the hand or arm, used by health care providers to give a person medicine or fluids), but unable to revive Resident 1. Resident 1 was pronounced dead at 6:30 AM and Resident 1 ' s primary care physician (PCP) 1 and Family (FAM) 1 were notified by leaving a message. During a phone interview on [DATE] at 4:20 pm with LVN 1, LVN 1 stated on [DATE], between 5 am to 6 am (unable to recall the exact time), RNS 1 told LVN 1 to go to Resident 1 ' s room. LVN 1 stated when LVN 1 got to Resident 1 ' s room, LVN 1 found Resident 1 was lying on the floor and CNA 1 was standing around inside the room and CNA 1 was not performing CPR. LVN 1 stated LVN 1 did not start CPR after LVN 1 found Resident 1 on the floor because LVN 1 left Resident 1 ' s room to ask RNS 1 what LVN 1 was supposed to do. LVN 1 stated LVN 1 went back inside Resident 1 ' s room with CNA 2, and LVN 1, CNA 1, and CNA 2 put Resident 1 back in bed. LVN 1 stated LVN 1 realized Resident 1 did not have a pulse after Resident 1 was in bed. LVN 1 stated LVN 1 started chest compressions on Resident 1 until the paramedics arrived and the EMTs told LVN 1 to stop CPR. LVN 1 stated from what LVN 1 remembered from CPR training, chest compressions had to be performed immediately once a person stopped breathing and had no pulse. During a phone interview on [DATE] at 7:19 pm with RNS 1, RNS 1 stated on [DATE] at 5:55 am, CNA 1 notified RNS 1 Resident 1 was lying on the floor. RNS 1 stated RNS 1 went to Resident 1 ' s room with CNA 1 and found Resident 1 lying on the floor. RNS 1 stated RNS 1 checked for Resident 1 ' s pulse, on Resident 1 ' s neck and wrist (press with two [2] to three [3] fingers and feel for a pulse on the side of the neck closer to the rescuer). RNS 1 stated Resident 1 ' s pulse was weak and the rise and fall (describes the physical action of breathing) of Resident 1 ' s chest was hard to notice. RNS 1 stated Resident 1 did not respond nor say anything when RNS 1 spoke to or shook Resident 1 and Resident 1 ' s eyes remained closed. RNS 1 stated RNS 1 left CNA 1 in the room with Resident 1, and RNS 1 left Resident 1 ' s room to called 911. RNS 1 stated RNS 1 called a code blue and found LVN 1 and told LVN 1 to provide CPR to Resident 1. RNS 1 stated, RNS 1 did not start CPR because Resident 1 was still warm and RNS 1 was able to feel a faint (weak) pulse. RNS 1 stated, Resident 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 4 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was yawning (uncontrolled opening of the mouth and taking a long, deep breath of air), meaning Resident 1 was still alive. RNS 1 stated when RNS 1 went back to Resident 1 ' s room, Resident 1 was in bed and LVN 1 was performing compressions on Resident 1 ' s chest. RNS 1 stated It was important to start CPR right away to save the patient. During a phone interview on [DATE] at 9:45 am with CNA 1, CNA 1 stated when CNA 1 walked inside Resident 1 ' s room to answer Resident 1 ' s call light (device used by a resident to signal their need for assistance), on [DATE] between 5 am to 6 am (unable to recall the exact time), CNA 1 found Resident 1 sliding out of the bed. CNA 1 stated CNA 1 turned Resident 1 ' s overbed light on and when CNA 1 turned around, Resident 1 was lying on Resident 1 ' s back on the floor. CNA 1 stated Resident 1 ' s eyes were closed, and Resident 1 was unresponsive. CNA 1 stated CNA 1 left Resident 1 ' s room to get help and informed RNS 1 Resident 1 fell and was unresponsive. CNA 1 stated, when RNS 1 and CNA 1 went back into Resident 1 ' s room, RNS 1 and CNA 1 could not find Resident 1 ' s pulse and Resident 1 started gasping for air three (3) to four (4) times. CNA 1 stated neither RNS 1 nor CNA 1 started CPR on Resident 1. CNA 1 stated RNS 1 left Resident 1 ' s room to call 911 and CNA 1 left Resident 1 ' s room to get LVN 1. CNA 1 stated LVN 1, CNA 1, and CNA 2 put disposable isolation gowns (one-use gown used by health care personnel to protect the wearer from coming in contact with blood, body fluids, and other infectious material) on and put Resident 1 back to bed. CNA 1 stated Resident 1 remained unresponsive while LVN 1, CNA 1, and CNA 2 put Resident 1 to bed. CNA 1 stated once in bed, LVN 1, CNA 1, and CNA 2 did not see Resident 1 ' s chest rise and fall. CNA 1 stated LVN 1 did not start CPR as soon as Resident 1 was put back to bed. CNA 1 stated LVN 1 provided Resident 1 with two one and two compressions, (thirty [30] chest compressions, followed by two rescue breaths are considered one cycle), immediately before EMTs arrived. During a phone interview on [DATE] at 12:48 pm with CNA 2, CNA 2 stated on [DATE], between 5:30 am to 6 am, LVN 1 asked CNA 2 to help put Resident 1 in bed. CNA 2 stated once CNA 2, CNA 1, and LVN 1 put Resident 1 in bed, CNA 2, CNA 1, and LVN 1 did not see Resident 1 ' s chest rise for breaths. CNA 2 stated CNA 2 and LVN 1 checked Resident 1 ' s neck and wrist for a pulse, and CNA 2 stated CNA 2 could not find Resident 1 ' s pulse. CNA 2 stated CNA 2 did not know if LVN 1 found Resident 1 ' s pulse. CNA 2 stated LVN 1 left the room after they put Resident 1 to bed. CNA 2 stated, In CPR class, if unable to find pulse, begin chest compressions right away. CNA 2 stated CNA 2 did not start CPR. CNA 2 stated Resident 1 ' s room did not have an oxygen tank (a container with oxygen inside it, used for helping people to breathe) and neither LVN 1, CNA 1, nor CNA 2 provided Resident 1 with mouth-to-mouth resuscitation (to revive from apparent death or from unconsciousness). CNA 2 stated LVN 1 returned to Resident 1 ' s room and started CPR on Resident 1 only for a few seconds, no more than a minute. During a concurrent observation and interview on [DATE] at 2:10 pm with the ADON and the Medical Records Director (MRD), in the front office of the facility, the ADON and the MRD watched the video recording, dated [DATE] between 5:42 am to 6:09 am, from Station 1 ' s security camera (a camera used to monitor activity in Nursing Station (NS) 1 ' s hallway, hallway where Resident 1 ' s room was located). The video showed the following on [DATE]: 1. At 5:42:14 am, Resident 1 ' s call light turned on. 2. At 5:44:26 am, CNA 1 went inside Resident 1 ' s room. 3. At 5:44:46 am, CNA 1 was seen in Resident 1 ' s doorway, looking out towards the nurses ' station. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 5 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 0678 4. At 5:44:50 am, CNA 1 went inside Resident 1 ' s room. Level of Harm - Immediate jeopardy to resident health or safety 5. At 5:45:42 am, CNA 1 walked out of Resident 1 ' s room and walked towards Nursing Station (NS) 1. Residents Affected - Few 7. At 5:45:48 am, RNS 1 went inside Resident 1 ' s room. 6. At 5:45:42 am, CNA 1 went back inside Resident 1 ' s room. 8. At 5:47:41 am, RNS 1 walked out of Resident 1 ' s room and opened the Medication Cart (MC) 1 located in the hallway, against the wall to the right side of Resident 1 ' s room doorway. 9. At 5:48:24 am, RNS 1 went back inside Resident 1 ' s room. 10. At 5:49:13 am, RNS 1 walked out of Resident 1 ' s room and went to MC 1. 11. At 5:50:05 am, RNS 1 walked towards NS 1 and walked back towards Resident 1 ' s room with a blood pressure machine (device that automatically measures a person ' s blood pressure at set times and records the readings). 12. At 5:50:30 am, RNS 1 went inside Resident 1 ' s room with a BP machine. 13. At 5:52:48 am, RNS 1 walked out of Resident 1 ' s room with BP machine and went to MC 1. 14. At 5:52:56 am, CNA 1 walked out of Resident 1 ' s room and walked towards the NS 1. 15. At 5:53:25 am, RNS 1 left MC 1 and walked towards the NS 1. 16. At 5:54:39 am, LVN 1 and CNA 1 went inside Resident 1 ' s room. 17. At 5:55:52 am, LVN 1 walked out of Resident 1 ' s room and walked towards NS 1. 18. At 5:57:08 am, LVN 1 went inside Resident 1 ' s room with CNA 2. 19. At 5:58:01 am, CNA 2 walked out of Resident 1 ' s room to don (put on) a yellow disposable isolation gown. 20. At 5:58:17 am, LVN 1 walked out of Resident 1 ' s room to don a yellow disposable isolation gown. 21. At 5:58:42 am, CNA 2 went inside Resident 1 ' s room. 22. At 5:58:58 am, CNA 1 walked out of Resident 1 ' s room to don a yellow disposable isolation gown. 23. At 5:59:37 am, CNA 1 went inside Resident 1 ' s room. 24. At 5:59:40 am, LVN 1 went inside Resident 1 ' s room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 6 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 0678 25. At 6:02:36 am, RNS 1 walked in through the front door of Station 1 which led to the front lobby. Level of Harm - Immediate jeopardy to resident health or safety 26. At 6:02:51 am, LVN 1 walked out of Resident 1 ' s room and grabbed an item (unidentified) from MC 1. Residents Affected - Few 28. At 6:02:55 am, LVN 1 walked out of Resident 1 ' s room and went to MC 1. 27.At 6:02:52 am, LVN 1 went inside Resident 1 ' s room. 29. At 6:03:23 am, RNS 1 went inside Resident 1 ' s room, walked out of Resident 1 ' s room, and stopped to talk to LVN 1 who was in front of MC 1. 30. At 6:03:53 am, RNS 1 walked toward NS 1. 31. At 6:04:09 am, LVN 1 went inside Resident 1 ' s room. 32. At 6:04:30 am, RNS 1 went inside Resident 1 ' s room. 33. At 6:05:21 am, CNA 2 walked out of Resident 1 ' s room. 34. At 6:05:25 am, RNS 1 walked out of Resident 1 ' s room with a BP machine and CNA 2 went inside Resident 1 ' s room. 35. At 6:05:31 am, RNS 1 opened MC 1. 36. At 6:05:37 am, LVN 1 walked out of Resident 1 ' s room and went to MC 1 where RNS 1 was. 37. At6:05:44 am, RNS 1 walked towards NS 1. 38. At 6:05:46 am, LVN 1 went inside Resident 1 ' s room with a BP machine. 39. At 6:05:55 am, CNA 2 walked out of Resident 1 ' s room and walked towards NS 1. 40. At 6:06:03 am, LVN 1 walked towards NS 1 then went to MC 1. 41. At 6:06:20 am, CNA 2 went inside Resident 1 ' s room. 42. At 6:07:10 am, LVN 1 walked towards NS 1. 43. At 6:07:44 am, a paramedic (EMT 1) walked through the front door of Station 1. 44. At 6:07:51 am, EMT 2 walked through the front door at Station 1. 45. At 6:08:00 am, EMT 1 went inside Resident 1 ' s room. 46. At 6:08:04 am, LVN 1 went inside Resident 1 ' s room. 47. At 6:08:06 am, EMT 2 went inside Resident 1 ' s room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 7 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 0678 48. At 6:08:12 am, an unidentified staff seen with an emergency cart headed towards Resident 1 ' s room. Level of Harm - Immediate jeopardy to resident health or safety 49. At 6:08:19 am, an unidentified staff went inside Resident 1 ' s room and left the emergency cart outside the room. 50. At 6:08:30 am, EMT 3 walked in through Station 1 ' s front door. Residents Affected - Few 51. At 6:08:37 am, EMT 4 and EMT 5 walked in through Station 1 ' s front door. 52. At 6:09:06 am, LVN 1 walked out of Resident 1 ' s room and the video ended. During an interview on [DATE] at 4:40 pm with the DON, the DON stated the DON expected nursing staff (in general) to immediately assess an unresponsive resident and request for additional help as needed. The DON stated when Resident 1 was on the floor, unresponsive and not breathing, staff (in general) needed to provide Resident 1 with oxygen. The DON stated once Resident 1 no longer had a pulse, then CPR needed to be started right away. The DON stated once CPR started, chest compressions needed to be continued until the EMTs, or another person(s) took over. The DON stated it was important to start CPR immediately to increase a resident ' s chances of recovery. The DON stated all nursing staff were required to have a current CPR certification card. During a review of the facility ' s CPR list of nursing staff without current CPR certification cards, dated [DATE], the list indicated ten of 61 CNAs (CNA 1, CNA 5, CNA 6, CNA 7, CNA 8, CNA 9, CNA 10, CNA 12, and CNA 13) and three of 35 LVNs (LVN 3, LVN 4, and LVN 5) did not have current CPR certification cards. During a review of the facility ' s policy and procedure (P&P) titled, Emergency Procedure – Cardiopulmonary Resuscitation, dated [DATE], the P&P indicated, If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual, or there are obvious signs of irreversible death. The P&P indicated the facility will provide periodic Mock Codes (simulations of an actual cardiac arrest) for training purposes. The P&P indicated, If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911; b. Verify or instruct a staff member to verify the DNR or code status of the individual; c. Initiate the basic life support (BLS) sequence of events. The BLS sequence of events is referred to as ' C-A-B ' (chest compressions, airway, breathing). Chest compressions: a. Following initial assessment, begin CPR with chest compressions. Minimize interruptions in chest compressions. All rescuers trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations (to supply oxygen to the patient's lungs). Continue with CPR/BLS until emergency medical personnel arrive. A review of the American Heart Association CRP & First Aid Emergency Cardiovascular Care website titled, Algorithms, dated 2023, the website indicated for adults, verify scene safety, check for responsiveness, shoutout for nearby help, activate emergency response system via mobile device (if appropriate), get AED and emergency equipment (or send someone to do so). The website indicated, look for no breathing or only gasping and check pulse (simultaneously) and if pulse is felt within 10 seconds with no normal breathing, then to provide rescue breathing, one (1) breath every six (6) seconds or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 8 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 0678 Level of Harm - Immediate jeopardy to resident health or safety 10 breaths per minute, check pulse every two (2) minutes and if no pulse, start CPR. The website indicated, when CPR is started, perform cycles of 30 chest compressions and two (2) breaths and use an AED as soon as it is available. The website indicated if it is determined a heart rhythm cannot be checked with an AED, resume CPR cycles until an ALS (advances life support) provider takes over or the victim starts to move. Residents Affected - Few [https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms#adult] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 9 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Registered Nurse Supervisor 1 (RNS 1), Licensed Vocational Nurse 1 (LVN 1), Certified Nursing Assistant 1 (CNA 1), and CNA 2 had the competency (the capability to apply or use the knowledge, skills, and abilities required to successfully perform tasks in the work setting) to provide cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of chest compressions and mouth-to-mouth or mechanical breaths, performed when the heart stops beating or beats ineffectively and/or to restore breathing) and to recognize when to provide CPR when: 1. On [DATE] at 5:45 am (as indicated in the video recording), Registered Nurse Supervisor 1 (RNS 1) and Certified Nursing Assistant 1 (CNA 1) did not start CPR after RNS 1 and CNA 1 found Resident 1 on the floor, in Resident 1 ' s room, unresponsive (not reacting to anything) with a weak pulse (movement of blood caused by the beating of the heart and that can be felt by touching certain parts of the body) and not breathing. 2. On [DATE], Licensed Vocational Nurse 1 (LVN 1), CNA 1, and CNA 2 did not start CPR after LVN 1, CNA 1, and CNA 2 put Resident 1 in bed, and found Resident 1 without a pulse and not breathing. 3. RNS 1 ' s, LVN 1 ' s, CNA 1 ' s, and CNA 2 ' s competency to provide CPR and to recognize when to provide CPR was not evaluated upon hire and/or yearly. These failures resulted in Resident 1, who had full code status (means if the resident ' s heart stopped beating and/or the resident stopped breathing, the resident or their representative wishes for all lifesaving procedures to be provided to keep them alive), to die on [DATE] at 6:30 am, after unsuccessful CPR was provided by paramedics (emergency medical technicians [EMT] who provide emergency medical services) in Resident 1 ' s room. These failures also had the potential to result in 87 residents in the facility with full code status to not be provided CPR if their heart stopped beating and/or if they stopped breathing. Cross-reference F678 Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility readmitted Resident 1 on [DATE] with diagnoses which included end stage renal disease (ESRD, a medical condition in which a person ' s kidneys permanently stop working and can no longer clean waste products from the blood and send waste products out of the body in urine). During a review of Resident 1 ' s History and Physical (H&P, physician ' s clinical evaluation and examination of the resident), dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], the MDS indicated Resident 1 required touching or steadying assistance with toileting, dressing and personal hygiene (includes combing hair, shaving, washing/drying face and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 10 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hands). The MDS also indicated Resident 1 required partial assistance to transfer to and from bed to chair/wheelchair, and to get on and off a toilet. During a review of Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner, or a physician assistant which specifies what a patient ' s lifesaving treatment wishes are), dated [DATE], the POLST indicated Resident 1 had full code status and wanted all lifesaving procedures to be provided to him if his heart stopped and/or if he stopped breathing. During a review of Resident 1 ' s EMTs run report (a standard document used by emergency medical service care providers), dated [DATE] and timed 5:59 am, the report indicated EMTs arrived at the facility on [DATE] at 6:07 am and was at Resident 1 ' s bedside to evaluate Resident 1 at 6:08 am. The report indicated the EMTs found Resident 1 in bed, unresponsive and pulseless (without a pulse), and the EMTs started CPR on Resident 1 on [DATE] at 6:10 am. The report indicated Resident 1 ' s first monitored heart rhythm (electrical activity of the heart seen on a screen) was asystole (no heartbeat) and Resident 1 remained with no heartbeat after 20 minutes of CPR. The report indicated the time of Resident 1 ' s death was [DATE] at 6:30 am. During a review of Resident 1 ' s Situation, Background, Appearance, Review (SBAR, a standardized communication tool between healthcare providers) form signed by LVN 1, dated [DATE] and timed 6:30 am, the SBAR indicated Resident 1 had a change of condition identified on [DATE] at 5:55 am. The SBAR indicated Resident fell, had a change in level of consciousness (LOC, a medical term that describes a person ' s stated of awareness, alertness, and wakefulness), and had full code status with a blood oxygen level of zero (0, healthy blood oxygen level is 75–100 millimeters of mercury [mm Hg, unit of pressure] or 95–100 percent [%, number of ratio expressed as a fraction of 100]). The SBAR indicated Resident 1 fell, had a change in level of consciousness (LOC, a medical term that describes a person ' s stated of awareness, alertness, and wakefulness), and had full code status. The SBAR indicated at 5:55 am, CNA 1 reported to RNS 1 Resident 1 was on the floor. Resident 1 was assessed by RNS 1, noted unresponsive, with initial vital signs of: blood pressure (BP, ideal BP is considered to be between 90/60 mm Hg, unit of and 120/80mmHg) of 46/26 mmHg, pulse at 39 (normal resting heart rate is from 60 to 100 beats per minute [BPM]), blood sugar at 222 milligrams per deciliter (mg/dl – units of measurement, normal fasting blood glucose concentration are between 70 mg/dL and 100 mg/dL). The SBAR indicated RNS 1 rechecked Resident 1 ' s vital signs (heart rate/HR, respiration rate/RR and BP) and Resident 1 had no pulse or zero (0 breaths per minute, normal RR for adults at rest is 12 to 18 breaths per minute) signs of breathing noted. The SBAR indicated CPR was initiated (unspecified person), 911 (emergency number for police, fire, paramedics) was called and the paramedics arrived at 6:07 am. The SBAR indicated the paramedics took over care, however, Resident 1 was unable to be revived (restore to life or consciousness) and pronounced dead by the paramedics at 6:30 am. During a review of Resident 1 ' s Licensed Nursing Note written by RNS 1, dated [DATE] and timed 6:50 am, the Nursing Note indicated at 5:55 am, (nurse assigned to Resident 1, CNA 1) reported to supervisor (RNS 1) that resident was on the floor. The note indicated RNS 1 got to Resident 1 ' s room immediately and Resident 1 was on the floor. The note indicated RNS 1 assessed (Resident 1), pat Resident 1 ' s shoulder, but Resident 1 was not responsive (state of being responsive). The note indicated Resident 1 ' s pulse can hardly be appreciated (palpable, felt by touch) by RNS 1 and rise and fall (describes the physical action of breathing) of Resident 1 ' s chest was absent. The note indicated Resident 1 ' s BP was 46/26 mm Hg, the HR was 39 BPM. The note indicated (unspecified person) started CPR, called 911, the paramedics arrived at 6:07 am and took over care. The noted indicated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 11 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some paramedic started IV (intravenous line - a soft, flexible tube placed inside a vein, usually in the hand or arm, used by health care providers to give a person medicine or fluids), but unable to revive Resident 1. Resident 1 was pronounced dead at 6:30 AM and Resident 1 ' s primary care physician (PCP) 1 and Family (FAM) 1 were notified by leaving a message. During a phone interview on [DATE] at 4:20 pm with LVN 1, LVN 1 stated on [DATE], between 5 am to 6 am (unable to recall the exact time), RNS 1 told LVN 1 to go to Resident 1 ' s room. LVN 1 stated when LVN 1 got to Resident 1 ' s room, LVN 1 found Resident 1 was lying on the floor and CNA 1 was standing around inside the room and CNA 1 was not performing CPR. LVN 1 stated LVN 1 did not start CPR after LVN 1 found Resident 1 on the floor because LVN 1 left Resident 1 ' s room to ask RNS 1 what LVN 1 was supposed to do. LVN 1 stated LVN 1 went back inside Resident 1 ' s room with CNA 2, and LVN 1, CNA 1, and CNA 2 put Resident 1 back in bed. LVN 1 stated LVN 1 realized Resident 1 did not have a pulse after Resident 1 was in bed. LVN 1 stated LVN 1 started chest compressions on Resident 1 until the paramedics arrived and the EMTs told LVN 1 to stop CPR. LVN 1 stated from what LVN 1 remembered from CPR training, chest compressions had to be performed immediately once a person stopped breathing and had no pulse. During a phone interview on [DATE] at 7:19 pm with RNS 1, RNS 1 stated on [DATE] at 5:55 am, CNA 1 notified RNS 1 Resident 1 was lying on the floor. RNS 1 stated RNS 1 went to Resident 1 ' s room with CNA 1 and found Resident 1 lying on the floor. RNS 1 stated RNS 1 checked for Resident 1 ' s pulse, on Resident 1 ' s neck and wrist (press with two [2] to three [3] fingers and feel for a pulse on the side of the neck closer to the rescuer). RNS 1 stated Resident 1 ' s pulse was weak and the rise and fall (describes the physical action of breathing) of Resident 1 ' s chest was hard to notice. RNS 1 stated Resident 1 did not respond nor say anything when RNS 1 spoke to or shook Resident 1 and Resident 1 ' s eyes remained closed. RNS 1 stated RNS 1 left CNA 1 in the room with Resident 1, and RNS 1 left Resident 1 ' s room to called 911. RNS 1 stated RNS 1 called a code blue and found LVN 1 and told LVN 1 to provide CPR to Resident 1. RNS 1 stated, RNS 1 did not start CPR because Resident 1 was still warm and RNS 1 was ablet to feel a faint (weak) pulse. RNS 1 stated, Resident 1 was yawning (uncontrolled opening of the mouth and taking a long, deep breath of air), meaning Resident 1 was still alive. RNS 1 stated when RNS 1 went back to Resident 1 ' s room, Resident 1 was in bed and LVN 1 was performing compressions on Resident 1 ' s chest. RNS 1 stated It was important to start CPR right away to save the patient. During a phone interview on [DATE] at 9:45 am with CNA 1, CNA 1 stated when CNA 1 walked inside Resident 1 ' s room to answer Resident 1 ' s call light (device used by a resident to signal their need for assistance), on [DATE] between 5 am to 6 am (unable to recall the exact time), CNA 1 found Resident 1 sliding out of the bed. CNA 1 stated CNA 1 turned Resident 1 ' s overbed light on and when CNA 1 turned around, Resident 1 was lying on Resident 1 ' s back on the floor. CNA 1 stated Resident 1 ' s eyes were closed, and Resident 1 was unresponsive. CNA 1 stated CNA 1 left Resident 1 ' s room to get help and informed RNS 1 Resident 1 fell and was unresponsive. CNA 1 stated, when RNS 1 and CNA 1 went back into Resident 1 ' s room, RNS 1 and CNA 1 could not find Resident 1 ' s pulse and Resident 1 started gasping for air three (3) to four (4) times. CNA 1 stated neither RNS 1 nor CNA 1 started CPR on Resident 1. CNA 1 stated RNS 1 left Resident 1 ' s room to call 911 and CNA 1 left Resident 1 ' s room to get LVN 1. CNA 1 stated LVN 1, CNA 1, and CNA 2 put disposable isolation gowns (one-use gown used by health care personnel to protect the wearer from coming in contact with blood, body fluids, and other infectious material) on and put Resident 1 back to bed. CNA 1 stated Resident 1 remained unresponsive while LVN 1, CNA 1, and CNA 2 put Resident 1 to bed. CNA 1 stated once in bed, LVN 1, CNA 1, and CNA 2 did not see Resident 1 ' s chest rise and fall. CNA 1 stated LVN 1 did not start CPR as soon as Resident 1 was put back to bed. CNA 1 stated LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 12 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1 provided Resident 1 with two one and two compressions, (thirty [30] chest compressions, followed by two rescue breaths are considered one cycle), and then the EMTs arrived. During a phone interview on [DATE] at 12:48 pm with CNA 2, CNA 2 stated on [DATE], between 5:30 am to 6 am, LVN 1 asked CNA 2 to help put Resident 1 in bed. CNA 2 stated once CNA 2, CNA 1, and LVN 1 put Resident 1 in bed, CNA 2, CNA 1, and LVN 1 did not see Resident 1 ' s chest rise for breaths. CNA 2 stated CNA 2 and LVN 1 checked Resident 1 ' s neck and wrist for a pulse, and CNA 2 stated CNA 2 could not find Resident 1 ' s pulse. CNA 2 stated CNA 2 did not know if LVN 1 found Resident 1 ' s pulse. CNA 2 stated LVN 1 left the room after they put Resident 1 to bed. CNA 2 stated, In CPR class, if unable to find pulse, begin chest compressions right away. CNA 2 stated CNA 2 did not start CPR. CNA 2 stated Resident 1 ' s room did not have an oxygen tank and LVN 1, CNA 1, nor CNA 2 provided Resident 1 with mouth-to-mouth resuscitation (to revive from apparent death or from unconsciousness). CNA 2 stated LVN 1 returned to Resident 1 ' s room and started CPR on Resident 1 only for a few seconds, no more than a minute. During a concurrent observation and interview on [DATE] at 2:10 pm with the ADON and the Medical Records Director (MRD), in the front office of the facility, the ADON and the MRD watched the video recording, dated [DATE] between 5:42 am to 6:09 am, from Station 1 ' s security camera (a camera used to monitor activity in Nursing Station (NS) 1 ' s hallway, hallway where Resident 1 ' s room was located). The video showed the following on [DATE]: 1. At 5:42:14 am, Resident 1 ' s call light turned on. 2. At 5:44:26 am, CNA 1 went inside Resident 1 ' s room. 3. At 5:44:46 am, CNA 1 was seen in Resident 1 ' s doorway, looking out towards the nurses ' station. 4. At 5:44:50 am, CNA 1 went inside Resident 1 ' s room. 5. At 5:45:42 am, CNA 1 walked out of Resident 1 ' s room and walked towards Nursing Station (NS) 1. 6. At 5:45:42 am, CNA 1 went back inside Resident 1 ' s room. 7. At 5:45:48 am, RNS 1 went inside Resident 1 ' s room. 8. At 5:47:41 am, RNS 1 walked out of Resident 1 ' s room and opened the Medication Cart (MC) 1 located in the hallway, against the wall to the right side of Resident 1 ' s room doorway. 9. At 5:48:24 am, RNS 1 went back inside Resident 1 ' s room. 10. At 5:49:13 am, RNS 1 walked out of Resident 1 ' s room and went to MC 1. 11. At 5:50:05 am, RNS 1 walked towards NS 1 and walked back towards Resident 1 ' s room with a blood pressure machine (device that automatically measures a person ' s blood pressure at set times and records the readings). 12. At 5:50:30 am, RNS 1 went inside Resident 1 ' s room with a BP machine. 1313. At 5:52:48 am, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 13 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 0726 RNS 1 walked out of Resident 1 ' s room with BP machine and went to MC 1. Level of Harm - Minimal harm or potential for actual harm 14. At 5:52:56 am, CNA 1 walked out of Resident 1 ' s room and walked towards the NS 1. 15. At 5:53:25 am, RNS 1 left MC 1 and walked towards the NS 1. Residents Affected - Some 16. At 5:54:39 am, LVN 1 and CNA 1 went inside Resident 1 ' s room. 17. At 5:55:52 am, LVN 1 walked out of Resident 1 ' s room and walked towards NS 1. 18. At 5:57:08 am, LVN 1 went inside Resident 1 ' s room with CNA 2. 19. At 5:58:01 am, CNA 2 walked out of Resident 1 ' s room to don (put on) a yellow disposable isolation gown. 20. At 5:58:17 am, LVN 1 walked out of Resident 1 ' s room to don a yellow disposable isolation gown. 21. At 5:58:42 am, CNA 2 went inside Resident 1 ' s room. 22. At 5:58:58 am, CNA 1 walked out of Resident 1 ' s room to don a yellow disposable isolation gown. 23. At 5:59:37 am, CNA 1 went inside Resident 1 ' s room. 24. At 5:59:40 am, LVN 1 went inside Resident 1 ' s room. 25. At 6:02:36 am, RNS 1 walked in through the front door of Station 1 which led to the front lobby. 26. At 6:02:51 am, LVN 1 walked out of Resident 1 ' s room and grabbed an item (unidentified) from MC 1. 27.At 6:02:52 am, LVN 1 went inside Resident 1 ' s room. 28. At 6:02:55 am, LVN 1 walked out of Resident 1 ' s room and went to MC 1. 29. At 6:03:23 am, RNS 1 went inside Resident 1 ' s room, walked out of Resident 1 ' s room, and stopped to talk to LVN 1 who was in front of MC 1. 30. At 6:03:53 am, RNS 1 walked toward NS 1. 31. At 6:04:09 am, LVN 1 went inside Resident 1 ' s room. 32. At 6:04:30 am, RNS 1 went inside Resident 1 ' s room. 33. At 6:05:21 am, CNA 2 walked out of Resident 1 ' s room. 34. At 6:05:25 am, RNS 1 walked out of Resident 1 ' s room with a BP machine and CNA 2 went inside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 14 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 0726 Resident 1 ' s room. Level of Harm - Minimal harm or potential for actual harm 35. At 6:05:31 am, RNS 1 opened MC 1. 36. At 6:05:37 am, LVN 1 walked out of Resident 1 ' s room and went to MC 1 where RNS 1 was. Residents Affected - Some 37. At6:05:44 am, RNS 1 walked towards NS 1. 38. At 6:05:46 am, LVN 1 went inside Resident 1 ' s room with a BP machine. 39. At 6:05:55 am, CNA 2 walked out of Resident 1 ' s room and walked towards NS 1. 40. At 6:06:03 am, LVN 1 walked towards NS 1 then went to MC 1. 41. At 6:06:20 am, CNA 2 went inside Resident 1 ' s room. 42. At 6:07:10 am, LVN 1 walked towards NS 1. 43. At 6:07:44 am, a paramedic (EMT 1) walked through the front door of Station 1. 44. At 6:07:51 am, EMT 2 walked through the front door at Station 1. 45. At 6:08:00 am, EMT 1 went inside Resident 1 ' s room. 46. At 6:08:04 am, LVN 1 went inside Resident 1 ' s room. 47. At 6:08:06 am, EMT 2 went inside Resident 1 ' s room. 48. At 6:08:12 am, an unidentified staff seen with an emergency cart [a cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate (to revive from apparent death or from unconsciousness) a patient experiencing cardiac arrest] headed towards Resident 1 ' s room. 49. At 6:08:19 am, an unidentified staff went inside Resident 1 ' s room and left the emergency cart outside the room. 50. At 6:08:30 am, EMT 3 walked in through Station 1 ' s front door. 51. At 6:08:37 am, EMT 4 and EMT 5 walked in through Station 1 ' s front door. 52. At 6:09:06 am, LVN 1 walked out of Resident 1 ' s and the video ended. During an interview on [DATE] at 4:40 pm with the DON, the DON stated the DON expected nursing staff (in general) to immediately assess an unresponsive resident and request for additional help as needed. The DON stated when Resident 1 was on the floor, unresponsive and not breathing, staff (in general) needed to provide Resident 1 with oxygen. The DON stated once Resident 1 no longer had a pulse, then CPR needed to be started right away. The DON stated once CPR started, chest compressions needed to be continued until the EMTs, or another person(s) took over. The DON stated it was important to start CPR immediately to increase a resident ' s chances of recovery. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 15 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of RNS 1 ' s Basic Life Support (BLS, medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at a hospital, and may include recognition of sudden cardiac arrest [when the heart stops beating suddenly], activation of the emergency response system, early cardiopulmonary resuscitation, and rapid defibrillation [stopping the uncontrolled twitching of the heart] with an automated external defibrillator [portable electronic device that analyzes the heart ' s rhythm and, if necessary, deliver an electrical shock], if available) Provider Certificate, the certificate indicated RNS 1 was certified on [DATE] and had to recertify by 02/2024. During a review of CNA 1 ' s BLS Provider Certificate, the certificate indicated CNA 1 was certified on [DATE] and had to recertify on 5/2023. During a review of LVN 1 ' s BLS Provider Certificate, the certificate indicated LVN 1 was certified on [DATE] and had to recertify by 02/2024. During a review of CNA 2 ' s BLS Provider Certificate, the certificate indicated CNA 2 was certified on [DATE] and had to recertify by 11/2024. During a review of RNS 1 ' s Competency Check Lists, dated [DATE] and [DATE], the checklist indicated RNS 1 ' s competency to provide CPR and to recognize when to provide CPR was not evaluated yearly. During a review of LVN 1 ' s Competency Check Lists, dated [DATE] and [DATE], the checklist indicated LVN 1 ' s competency to provide CPR and to recognize when to provide CPR was not evaluated yearly. During a review of CNA 1 ' s Competency Check List, dated [DATE], the checklist indicated CNA 1 ' s competency to provide CPR and to recognize when to provide CPR was not evaluated upon hire. During a review of CNA 2 ' s Competency Check List, dated [DATE], the checklist indicated CNA 2 ' s competency to provide CPR and to recognize when to provide CPR was not evaluated upon hire. During a review of the facility ' s policy and procedure (P&P) titled, Emergency Procedure – Cardiopulmonary Resuscitation, dated [DATE], the P&P indicated, If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual, or there are obvious signs of irreversible death. The P&P indicated the facility will provide periodic Mock Codes (simulations of an actual cardiac arrest) for training purposes. The P&P indicated, If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911; b. Verify or instruct a staff member to verify the DNR or code status of the individual; c. Initiate the basic life support (BLS) sequence of events. The BLS sequence of events is referred to as ' C-A-B ' (chest compressions, airway, breathing). Chest compressions: a. Following initial assessment, begin CPR with chest compressions .d. Minimize interruptions in chest compressions .All rescuers trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations .Continue with CPR/BLS until emergency medical personnel arrive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 16 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the American Heart Association ' s 2020 Adult Basic Life Support Algorithm (a list of steps to take when responding to a situation that may require basic life support) for Healthcare Providers, the algorithm indicated upon finding an unconscious person with a pulse and who was gasping or not breathing normally, provide 1 breath every 6 seconds, check pulse every 2 minutes, and if they have no pulse, start CPR. The algorithm indicated upon finding an unconscious person who was not breathing or gasping and had no pulse, start CPR, and continue CPR until the paramedics take over or the victim starts to move. During a review of the facility ' s policy and procedure (P&P) titled, Competency Assessment, undated, the P&P indicated, Employees will be assessed for competency upon hire and annually (yearly). The P&P indicated, 1. Each department will have its own competency assessment form to be utilized for new employees during the initial orientation period. 2. Subsequent (following) competencies will be completed annually for employees by department heads. 3. Competencies will be utilized to identify areas that need to be incorporated in the in-service education for each department. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 17 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the clinical record for one of three sampled residents (Resident 1) was complete and accurate when Resident 1 ' s clinical record did not indicate there was blood on the back of Resident 1 ' s head after a fall on [DATE]. This failure had the potential for Resident 1 to not get the appropriate care and treatment. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility readmitted Resident 1 on [DATE] with diagnoses which included end stage renal disease (ESRD, a medical condition in which a person ' s kidneys permanently stop working and can no longer clean waste products from the blood and send waste products out of the body in urine). During a review of Resident 1 ' s History and Physical (H&P, physician ' s clinical evaluation and examination of the resident), dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], the MDS indicated Resident 1 required touching or steadying assistance with toileting, dressing and personal hygiene (includes combing hair, shaving, washing/drying face and hands). The MDS also indicated Resident 1 required partial assistance to transfer to and from bed to chair/wheelchair, and to get on and off a toilet. During a review of Resident 1 ' s Situation, Background, Appearance, Review (SBAR, a standardized communication tool between healthcare providers) form signed by Licensed Vocational Nurse 1 (LVN 1), dated [DATE] and timed 6:30 am, the SBAR indicated on [DATE] at 5:55 am, Resident 1 was found on the floor unresponsive (not reacting to anything) with no pulse and not breathing. The SBAR indicated CPR was provided to Resident 1. The SBAR indicated 911 (emergency number for police, fire, paramedics [emergency medical technicians (EMT) who provide emergency medical services]) was called and the paramedics came and was unable to revive Resident 1. The SBAR did not indicate there was blood on the back of Resident 1 ' s head. During a review of Resident 1 ' s clinical record, there was no documented evidence found there was blood in the back of Resident 1 ' s head after a fall on [DATE]. During an interview on [DATE] at 3:05 pm with Resident 1 ' s primary care physician (PCP) 1, PCP 1 stated the nurse (unidentified) PCP 1 talked to on the phone on [DATE] told PCP 1 Resident 1 fell and had blood in back of his head. PCP 1 stated for falls and head injuries, PCP 1 would tell the licensed nurse to do a neurological examination (an evaluation of a person ' s nervous system [includes the brain, the spinal cord, and the nerves) on the resident, refer the resident to a neurosurgeon (a medical doctor who diagnoses and treats conditions that affect the nervous system), and order a computed tomography scan (CT, a test that takes detailed pictures of the inside of the body) of the resident ' s head. During a phone interview on [DATE] at 4:20 pm with LVN 1, LVN 1 stated after LVN 1, Certified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 18 of 19 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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 Residents Affected - Few Nursing Assistant 1 (CNA 1), and CNA 2 put Resident 1 back in bed after Resident 1 fell, LVN 1 saw blood on the floor by the foot of Resident 1 ' s bed. During a phone interview on [DATE] at 7:19 pm with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated on [DATE] at 5:55 am, RNS 1 found Resident 1 on the floor, lying on Resident 1 ' s back, parallel to Resident 1 ' s bed. RNS 1 stated Resident 1 ' s head was by the foot (end of bed or near to the end of the bed) of Resident 1 ' s bed. RNS 1 stated Resident 1 had blood on the back of Resident 1 ' s head when RNS 1 and CNA 1 found Resident 1 unresponsive with a weak pulse and not breathing on the floor in Resident 1 ' s room. During a phone interview on [DATE] at 9:54 am with CNA 1, CNA 1 stated CNA 1 noticed blood on Resident 1 ' s gown when CNA 1 and RNS 1 found Resident 1 on the floor on [DATE]. CNA 1 stated CNA 1 could not tell Resident 1 was bleeding from the back of Resident 1 ' s head until CNA 1, CNA 2, and LVN 1 put Resident 1 back to bed. During an interview on [DATE] at 3:46 pm with the Director of Nursing (DON), the DON stated the DON did not know Resident 1 was bleeding from the head. The DON stated Resident 1 ' s SBAR, dated [DATE] and timed 6:30 am, did not indicate Resident 1 was bleeding from the head. During an interview on [DATE] at 4:21 pm with the DON, the DON stated the DON reviewed Resident 1 ' s clinical record and did not find documented evidence Resident 1 was bleeding from the head. The DON stated it was important to document correct information in the resident ' s clinical record so health care providers could provide appropriate care and treatment to the resident. During a review of the facility ' s policy and procedure (P&P) titled, Incidents/Accidents, undated, the P&P indicated incidents/accidents will be reported to the charge nurse and documented on the accident/incident report as soon as they occur. Charge nurse initiating the report will be responsible for the completeness and accuracy of the information contained in the report [ .] The P&P indicated Nursing assessment and documentation of incident [ .] to include complete body check [ .]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056477 If continuation sheet Page 19 of 19