Health inspection·December 3, 2021

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Minimum Data Set (MDS- an assessment tool), dated September 16, 2021, indicated, Resident 18 had severely impaired cognitive status. A review of the Respiratory Therapy Progress Notes, from November 17, 2021 to December 1, 2021, was conducted. There was no documented evidence Resident 18 had an incident of removing the trach dressing. On December 1, 2021, at 5:15 p.m., Resident 18 was observed with Respiratory Therapist (RT) 1 to have no dressing at the trach site. In a concurrent interview with RT1, she stated the skin around the trach site was slightly red. She stated she applied a new dressing for Resident 18 at the start of her shift (around 7 a.m.). RT1 stated Resident 18 had a behavior of removing the trach dressing. She stated she should check trach dressing every hour to ensure it was not removed or dislodged. RT1 stated the trach dressing should be replaced each time Resident 18 removes it. On December 2, 2021, at 9:59 a.m., Resident 18 was observed awake and lying in bed. She was observed to be holding the trach dressing with her left hand. On December 2, 2021, at 10:08 a.m., an interview with RT 2 was conducted. She stated Resident 18 currently had a behavior of pulling on her trach dressing for the last two weeks. Resident 18 was concurrently observed with RT 2. RT 2 was observed to assess Resident 18's trach stoma. RT 2 stated the trach stoma looked a little bit red. She stated the trach dressing was to prevent skin breakdown from the trach tie. She stated the trach dressing should be checked at least every hour to ensure the trach dressing was not removed or dislodged. She also stated she would document it in the Respiratory Therapy Progress Notes every time the trach dressing was changed. On December 2, 2021, at 10:29 a.m., Resident 18 was observed with the RT Supervisor (RTS) to have slight redness at the trach site. During an interview and concurrent record review with the RTS, he stated he was not aware of Resident 18's behavior of removing her trach dressing. He stated trach care was to be done every shift which included applying new trach dressing and replacing when needed. He stated resident should be monitored at least every two hours to ensure proper placement of the trach dressing. He further stated the purpose of the trach dressing was to prevent skin breakdown and infection on the trach site. He stated there was no documentation Resident 18 removed the trach dressing and was replaced when it was removed. The RTS stated there should have been documentation when Resident 18's trach dressing was changed each time it was removed. On December 2, 2021, at 10:40 a.m., an interview with the Director of Nursing (DON) was conducted. He stated the trach dressing should be replaced at the start of the shift. He stated the trach dressing was to be used to prevent skin breakdown and infection around the trach site. The DON stated he was not aware Resident 18 had a behavior of pulling on her trach dressing. He statedResident 18's trach dressing should have been replaced with a new one every time the resident removed it. The DON further stated the behavior of Resident 18 of pulling on the trach dressing should have been documented in the resident's medical record. The undated facility's policy and procedure titled, Tracheostomy Care, was reviewed. The policy indicated .Tracheostomy care will be performed by the RT, RN (Registered Nurse), or LVN (License Vocational Nurse), who have been trained and passed the tracheostomy care skills competency .Remove old dressing and dispose of dressing following STANDARD PRECUATIONS, assess the tracheostomy site for evidence or signs of skin breakdown or infection .apply sterile tracheostomy dressing .document tracheostomy care in the medical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 2 of 6 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 055542 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Care Center 8487 Magnolia Avenue Riverside, CA 92504 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with the physician's order and facility's policy and procedure, for one of four residents observed during medication administration (Resident 12). This failure had the potential for a medication error to occur. Findings: On December 1, 2021, at 10:39 a.m., during medication administration observation with Licensed Vocational Nurse (LVN) 1, a bubble pack (a card containing medications) for Resident 12 had a label which indicated, .Famotidine (medication to prevent acid reflux) .20MG (mg- unit of measurement) TABLET .TAKE 1 (ONE) TABLET VIA (through) G-TUBE (gastrostomy tube- a tube inserted through the stomach) TWICE DAILY . In a concurrent interview with LVN 1, she stated Resident 12 was to receive all of his medications according to the Medication Administration Record (MAR). The MAR was concurrently reviewed with LVN 1. She stated the MAR indicated famotidine was to be administered by mouth to Resident 12. She stated she had been administering the famotidine to Resident 12 by mouth and not through the G-tube as indicated in the bubble pack label. On December 1, 2021, Resident 12's record was reviewed. Resident 12 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (lung failure). The physician order, dated April 25, 2020, indicated, Pepcid (famotidine) Tablet 20 MG .Give 1 (one) tablet orally every 12 hours . On December 1, 2021, at 12:18 p.m., an interview with the Director of Nursing (DON) was conducted. He stated the medication label on the bubble pack should be changed according to the facility's policy and procedure. He stated the label for the famotidine medication for Resident 12 should be the have been updated to reflect the correct route of administration by mouth and not through the G-tube. The facility's policy and procedure titled, Medication Administration, dated February 2013, was reviewed. The policy indicated, .Medications are administered as prescribed .good nursing principles and practices .Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule. Apply a direction change sticker to the label if directions have changes from the current order . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 3 of 6 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 055542 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Care Center 8487 Magnolia Avenue Riverside, CA 92504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were implemented in the kitchen when: Residents Affected - Some 1. The floor in the dry storage area had food debris. This had the potential to attract pests. 2. The ice machine bin (where the clean ice was stored) had a build-up of a dark black substance, that was removable with a white paper towel. 3. Portions of the kitchen ceiling were not completely repaired for proper cleaning and sanitation. 4. The food preparation sink did not have an air gap (space between the water outlet and the flood level of a fixture) to prevent back flow from the drain to the sink. These failures had the potential for the growth of harmful bacteria and cross contamination that could lead to food borne illnesses for a medically compromised population of three residents who received food from the kitchen out of a facility census of 38. Findings: 1. On November 29, 2021, at 8:50 a.m., during an initial tour of the kitchen with the Dietary [NAME] (DC), the dry storage area was observed to have food debris under the dry storage racks at the back corners. In a concurrent interview with the DC, she stated the floor should be maintained clean without food debris and to be swept twice daily. On November 30, 2021, at 9:28 a.m., during an interview with the Dietary Services Supervisor (DSS), she stated the dry storage area should be swept and mopped twice daily. She stated the dry storage room area should be kept clean. According to the Food Code 2017, published by the U.S. Food & Drug Administration, .Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues .The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests . 2. On November 29, 2021, at 8:50 a.m., during an observation in the kitchen, the ice machine located inside the kitchen was inspected and found to have brown residue in the bin which was removeable with a white paper towel. On November 29, 2021, at 10:15 a.m., the ice machine was inspected with the Maintenance Supervisor (MS). In a concurrent interview with the MS, he stated the ice machine should not have any dirt. He stated the ice machine should be cleaned once a month (between the 22nd-25th) of the month. He stated the ice machine was not cleaned as scheduled. On November 30, 2021, at 9:28 a.m., during an interview with the DSS, she stated no dirt should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 4 of 6 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 055542 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Care Center 8487 Magnolia Avenue Riverside, CA 92504 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 in the ice machine bin or evaporator. She stated the ice machine should be cleaned monthly and documented on the cleaning log. The facility's policy and procedure titled, Sanitation, dated 2018, was reviewed. The policy indicated, .ice which is used in connection with food or drink shall be from a sanitary source . Residents Affected - Some The facility's policy and procedure titled, Ice Machine Cleaning Procedures, dated 2020, was reviewed. The policy indicated, .Ice machine needs to be cleaned and sanitized monthly .internal components cleaned monthly or per manufacturer recommendation's [sic] . According to the Food Code 2017, published by the U.S. Food & Drug Administration, .surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers .and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms . 3. On November 29, 2021, at 8:50 a.m., during the initial kitchen tour, the ceiling was observed to have several portion not completely painted. On November 30, 2021, at 9:20 a.m., during an interview with the DSS, she stated the ceiling spots and bulges happened when it rained. She stated repairs had been made but the ceiling had not been painted and did not have a set date to paint them. According to the Food Code 2017, published by the U.S. Food & Drug Administration, .Walls and ceilings that are of smooth construction, nonabsorbent, and in good repair can be easily and effectively cleaned . 4. On November 29, 2021, at 8:50 a.m., during an initial tour in the kitchen with the DC, the food preparation sink was observed to not have an air gap. On December 1, 2021, at 10 a.m., during an interview with the DSS, she stated there was no air gap at the food preparation sink. She stated there should be an air gap. The facility's policy and procedure titled, Accident Prevention-Safety Precautions, dated 2018, indicated, .An air gap is the most reliable backflow prevention device .food preparation sinks .shall be drained through an air gap into an open floor sink According to the Food Code 2017, published by the U.S. Food & Drug Administration, .Improper plumbing installation or maintenance may result in potential health hazards such as cross connections, back siphonage or backflow. These conditions may result in the contamination of food, utensils, equipment, or other food-contact surfaces .A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use . backflow prevention is required by LAW, by .Providing an air gap as specified . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 5 of 6 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 055542 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Care Center 8487 Magnolia Avenue Riverside, CA 92504 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet the required 80 square feet per resident bedrooms in 15 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 14, 15, 16, 17, and 18). Findings: On November 29, 2021, at 10:15 a.m., the Administrator (ADM) was interviewed regarding the room sizes for resident Rooms 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 14, 15, 16, 17, and 18. He stated the rooms did not meet the space requirement of at least 80 square feet per resident in the above listed bedrooms. Rooms 1, 2, 3, 4, 5, 6, 7, 11, 12, 14, 15, 16, 17, and 18 had been set up as two-bed bedrooms. room [ROOM NUMBER] was set up as a four-bed bedroom. The facility document titled, Client Accommodations Analysis, dated November 29, 2021, was provided by the ADM. The document indicated the rooms set up as two-bed bedrooms measured 154 square feet or 77 square feet per resident (154/2 = 77). room [ROOM NUMBER] was set up as a four-bed bedroom, which measured 282.24 square feet or 70.56 square feet per resident (282.24/4 = 70.56). During the survey dates of November 29, 30, and December 1, 2, and 3, 2021, the above listed rooms were observed at different times of the day. All care and services provided to the residents residing in the listed rooms were able to be conducted without restrictions. Residents who were able to be interviewed stated they were comfortable in the space provided. Health record reviews did not indicate the health and safety of the residents residing in these rooms were compromised, based on the room measurements. The facility requested a continued waiver for Rooms 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 14, 15, 16, 17, and 18. Approval of the waiver is recommended. Granting this waiver will not adversely affect the residents' health and safety and is in accordance with the special needs of the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 6 of 6