Health inspection·January 11, 2024

F 0625 Level of Harm - Minimal harm or potential for actual harm Bed Hold policy, including the bed hold's duration, on admission to the facility and at the time of transfer to the acute hospital .current regulations require that the facility provide/offer a bed-hold of up to 7 (seven) days when a resident is transferred to the acute hospital .Nurse supervisor/charge nurse shall notify the resident/legal representative of his/her right to a bed-hold at the time of transfer to the hospital and complete the bed-hold notice . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 2 of 28 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 01/11/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an enteral feeding (a tube is inserted through the abdominal wall, through which liquid nutrition is administered) was provided within the safe timeframe to prevent bacterial growth in accordance with the enteral feeding manufacturer's recommendations, for one of 34 residents (Resident 30). This failure had the potential to result in food borne illness for Resident 30. Findings: On January 10, 2024, at 1:18 p.m., a concurrent observation and interview with Resident 30 was conducted. One bag of enteral tube feeding formula (Fibersource HN - type of formula) with a label indicating Resident 30's name and dated January 6, 2024, at 7 p.m., were observed hanging on the bedside pole in the resident's room. Resident 30's enteral feeding bag was observed to have approximately 400 milliliters (ml - unit of measurement) of enteral solution. In a concurrent interview with Resident 30, she stated she received enteral feeding on January 9, 2024, at 7 p.m., and was turned off on January 10, 2024, at around 5 a.m. On January 10, 2024, at 3:14 p.m., a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1 was conducted. She stated there was an enteral feeding bag of Fibersource HN hanging on the pole for Resident 30 when she started her shift this morning. During a concurrent record review with LVN 1, she stated Resident 30 had an order for enteral feeding of Fibersource HN to start at 7 p.m. and off at 5 a.m. daily. She further stated the enteral feeding bag can be used for several days after it was initially started. On January 10, 2024, Resident 30's record was reviewed. Resident 30 was admitted to the facility on [DATE], with diagnoses which included gastrostomy (surgical procedure used to insert a tube through the abdomen and into the stomach). A review of Resident 30's physician's order, dated December 29, 2023, indicated, .Enteral Feed Order every shift Nocturnal Enteral feeding: Formula: Fibersource HN 1.2 .Rate: 20ml (milliliters) x (times) 10 (ten) hours .START AT 7 PM (p.m.) AND OFF AT 5 AM (a.m.) . A review Resident 30's Medication Administration Record (MAR), from January 6 through 10, of 2024, indicated Resident 30 received enteral feeding daily (7 p.m. to 5 a.m.). On January 10, 2024, at 3:20 p.m., an interview with the Director of Nursing (DON) was conducted. He stated all enteral feeding can be used up to forty-eight hours (48 hours), after it was initially started, per manufacturer's guidelines. The DON stated Resident 30's enteral feeding of Fibersource HN that was dated January 6, 2024, at 7 p.m. and should have been discarded on January 8, 2024, at 5 a.m. The DON further stated the enteral feeding of Fiber Source HN was not changed within the required timeline for safe administration (forty-eight hours after it was started). A review of the Fibersource HN enteral feeding bag, it indicated, .DIRECTION FOR USE .use for a maximum of 48 hours after connection when proper technique is followed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 3 of 28 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 01/11/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure: 1. A risk for entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) assessment and least restrictive alternatives were conducted prior to use of bed rails, for sixteen of sixteen residents reviewed for bed rails (Residents 1, 2, 3, 4, 9, 13, 16, 22, 27, 28, 30, 31, 32, 35, 37, and 40). In addition, the risk for entrapment assessment did not indicate the resident's size and weight in relation to the dimensions of the bed being used for the resident according to the facility's policy and procedure. 2. The risk for entrapment assessments conducted were not specific to the bed rails being used by the residents, for six of sixteen residents reviewed for bed rails (Residents 2, 3, 16, 28, 37, and 40); and 3. An appropriate indication for the use of bed rails, for three of sixteen residents reviewed for bed rails (Residents 1, 2, and 9). These failures had the potential for residents to be at risk for injuries and entrapment. Findings: 1. On January 9, 2024, at 12:20 p.m., Resident 27 was observed lying in bed with bilateral (both) half-length bed rails raised. On January 11, 2024, Resident 27's record was reviewed. Resident 27 was admitted to the facility on [DATE], with diagnoses which included seizures (sudden uncontrolled electrical activity in the brain). A review of Resident 27's document titled, Bed Rails, dated March 3, 2023, indicated the use of pillows was used as alternative prior to the use of bed rails, and was ineffective. The document did not indicate the reason why the use of pillows was ineffective. There was no documented evidence other alternatives were used prior to the use of bed rails. A review of Resident 27's physician's order, dated November 22, 2023, indicated bilateral padded half-length side rails (bed rails) for seizure precaution. The facility documented titled, Bed System Measurement Device Test Results Worksheet (entrapment risk assessment), dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of bilateral half bed rails. The document indicated the entrapment risk assessment was conducted after the bed rail assessment on March 3, 2023 (five months after initiation of use of bed rails) and prior to the physician's order, dated November 22, 2023 (more than three months prior to the physician's order). In addition, the entrapment risk assessment did not indicate Resident 27's size and weight in relation to the dimension of the bed being used. 2. On January 9, 2024, at 3:36 p.m., Resident 2 was observed lying in bed with bilateral full (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 4 of 28 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 01/11/2024 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 0700 length bed rails raised. Level of Harm - Minimal harm or potential for actual harm On January 11, 2024, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included quadriplegia (unable to move both arms and legs) and muscle contractures (a permanent shortening of the muscles, tendons, or tissues). Residents Affected - Some A review of Resident 2's documented titled, Bed Rails, dated July 25, 2023, indicated the use of full-length side rails. In addition, the document did not specify other alternatives used, except visual and verbal reminders to use call lights. A review of Resident 2's physician order, dated January 9, 2024, indicated bilateral full-length side rails to keep low air loss mattress in place. There was no documented evidence of any medical reason for the use of bed rails, except to keep low air mattress in place. The facility documented titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of bilateral half bed rails. The document indicated bilateral half-length bed rails which was different from the bed rails assessment for the use of full length bed rails, completed on July 25, 2023, and the physician's order, dated January 9, 2024. In addition, the assessment did not indicate Resident 2's size and weight in relation to the dimension of the bed being used. 3. On January 9, 2024, at 3:17 p.m., Resident 1 was observed lying in bed with bilateral half-length bed rails raised. On January 11, 2024, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included vegetative state (brain disorder in which a person shows no signs of awareness). A review of Resident 1's document titled, Bed Rails, dated September 16, 2023, the use of bilateral half bed rails. The document indicated pillows were used as an alternative prior to the use of bed rails but did not indicate the reason why the use of pillows was not effective. A review of Resident 1's physician order, dated November 22, 2023, indicated bilateral half bed rails to keep loss air mattress in place. There was no documented evidence of any medical reason for the use of bed rails, except to keep low air mattress in place. The facility documented titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of bed rails. The entrapment risk assessment was conducted prior to the bed rail assessment on September 16, 2023 (one month prior to the use of bed rails), and the physician's order on November 22, 2023 (three months prior to the physician's order). In addition, the assessment did not indicate Resident 1's size and weight in relation to the dimension of the bed being used. 4. On January 9, 2024, at 3:15 p.m., Resident 9 was observed awake and sitting on the wheelchair. Resident 9's bed was observed to have bilateral padded half bed rails raised. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 5 of 28 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 01/11/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm On January 11, 2024, Resident 9's record was reviewed. Resident 9 was admitted to the facility on [DATE], with diagnosis which included quadriplegia (unable to move both arms and legs). A review of Resident 9's physician's order, dated November 22, 2023, indicated bilateral half side rails to keep low air mattress in place. Residents Affected - Some There was no documented evidence of any medical reason for the use of bed rails, except to keep low air mattress in place. A review of Resident 9's document titled, Bed Rails, dated November 25, 2023, did not indicate specific other alternatives used, except visual and verbal reminder, prior to the use of bilateral half bed rails. The documented titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of half bed rails. The assessment was conducted three months prior to the physician's order for bed rails on November 22, 2023, and bed rail assessment conducted on November 25, 2023. In addition, the assessment did not indicate Resident 9's size and weight in relation to the dimension of the bed being used. 5. On January 9, 2024, at 2:04 p.m., Resident 3 was observed lying in bed with full-length bed rails raised. On January 11, 2024, Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE], with diagnosis which included dementia (cognitive impairment) and obesity (overweight). A review of Resident 3's physician's order, dated February 9, 2023, indicated bilateral full-length side rails as enabler. A review of Resident 3's document titled, Bed Rails, dated March 14, 2023, indicated full length side rails as an enabler. In addition, the document did not indicate specific other alternatives used, except frequent staff monitoring. The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of bilateral half bed rails. The document indicated half-length bed rails which was different from the physician's order on February 9, 2023, and the bed rails assessment on March 14, 2023. The document indicated the assessment was conducted six months after the physician's order on February 9, 2023. In addition, the assessment did not indicate Resident 3's size and weight in relation to the dimension of the bed being used. 6. On January 9, 2024, at 2:10 p.m., Resident 32 was observed lying in bed with bilateral padded half-length bed rails raised. On January 11, 2024, Resident 32's record was reviewed. Resident 32 was admitted to the facility on [DATE], with diagnoses which included seizures. A review of Resident 32's physician order, dated June 1, 2023, indicated bilateral padded half-length side rails to keep mattress in place and for seizure precaution. A review of Resident 32's document titled, Bed Rails, dated June 1, 2023, indicated no other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 6 of 28 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 01/11/2024 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 0700 alternatives used, except pillows, prior to the use of bed rails. Level of Harm - Minimal harm or potential for actual harm The facility documented titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of bilateral half rails. The assessment was conducted two months after it was ordered on June 1, 2023. In addition, the assessment did not indicate Resident 32's size and weight in relation to the dimension of the bed being used. Residents Affected - Some 7. On January 9, 2024, at 12:01 p.m., Resident 37 was observed lying in bed with padded full-length bed rails raised. On January 11, 2024, Resident 37's record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body). A review of Resident 37's physician's order, dated November 22, 2023, indicated bilateral padded full-length side rails for seizure precaution. A review of Resident 37's document titled, Bed Rails, dated November 21, 2023, indicated full length side rails for seizure precaution. The document did not indicate specific other alternatives used, except pillows, prior to the use bilateral full bed rails. The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of bilateral half bed rails. The document indicated half-length side rails which was different from the bed rails assessment and physician's order of full length side rails on November 22, 2023. The assessment was conducted three months prior to the use of bed rails on November 22, 2023. In addition, the assessment did not indicate Resident 37's size and weight in relation to the dimension of the bed being used. 8. On January 9, 2024, at 1:57 p.m., Resident 22 was observed lying in bed with bilateral padded half-length bed rails raised. On January 11, 2024, Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses which included seizures. A review of Resident 22's physician's order, dated October 23, 2022, indicated bilateral padded half-length side rails for seizure precaution. A review of Resident 22's document titled, Bed Rails, dated June 23, 2023, did not indicate other alternatives used prior to use of bed rails, except to provide visual and verbal reminder. The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of half bed rails. The document was conducted 10 months after the physician's order on October 23, 2022, and two months after bed rail assessment on June 23, 2023. In addition, the assessment did not indicate Resident 22's size and weight in relation to the dimension of the bed being used. 9. On January 9, 2024, at 1:55 p.m., Resident 16 was observed lying in bed with full-length padded bed rails raised. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 7 of 28 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 01/11/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm On January 11, 2024, Resident 16's record was reviewed. Resident 16 was admitted to the facility on [DATE], with diagnoses which included seizure. A review of Resident 16's physician's order, dated January 1, 2021, indicated bilateral padded full-length side rails for seizure precaution. Residents Affected - Some A review of Resident 16's document titled, Bed Rails, dated June 16, 2023, indicated to use full length side rails for seizure precaution. The document did not indicate other alternatives used prior to the use of bed rails, except to provide visual and verbal reminder to use the call light. The documented titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of bilateral half bed rails. The document indicated an assessment for the use half-length side rails which was different from the physician's order on January 1, 2021, and bed rails assessment of the use of full-length side rails on June 16, 2023. In addition, the assessment did not indicate Resident 16's size and weight in relation to the dimension of the bed being used. 10. On January 9, 2024, at 2:14 p.m., Resident 31 was observed lying in bed with full-length bed rails raised. On January 11, 2024, Resident 31's record was reviewed. Resident 31 was admitted to the facility on [DATE], with diagnoses which included amyotrophic lateral sclerosis (a disease involving the nerves which affects the spinal cord and the brain). A review of Resident 31's physician's order, dated September 22, 2023, indicated bilateral full-length side rails as an enabler and to keep low air mattress in place. A review of Resident 31's document titled, Bed Rails, dated September 22, 2023, did not include other alternatives used prior to the use of bed rails, except the use pillows. The document did not indicate the reason why the use of pillows was not effective. The facility document, titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, was conducted one month prior to use of bed rails for Resident 31. In addition, the assessment did not indicate Resident 31's size and weight in relation to the dimension of the bed being used. 11. On January 9, 2024, at 12:04 p.m., Resident 35 was observed lying in bed with bilateral half-length bed rails raised. On January 11, 2024, Resident 35's record was reviewed. Resident 35 was admitted to the facility on [DATE], with diagnoses which included myopathy (type of muscle disease which causes weakness, stiffness, and cramps). A review of Resident 35's physician's order, dated December 4, 2023, indicated bilateral half-length bed rails as an enabler and to keep low air mattress in place. A review of Resident 35's document titled, Bed Rails, dated December 4, 2023, indicated the use of bilateral half bed rails. The document did not indicate other alternatives attempted prior to use of bed rails, except pillows. The document did not indicate a reason why the use of pillows was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 8 of 28 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 01/11/2024 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 0700 effective. Level of Harm - Minimal harm or potential for actual harm The documented titled Bed System Measurement Device Test Results Worksheet (entrapment risk assessment), dated August 15, 2023, was conducted four months prior to the physician's order and bed rail assessment for the use of bed rails on December 4, 2023. In addition, the assessment did not indicate Resident 35's size and weight in relation to the dimension of the bed being used. Residents Affected - Some 12. On January 9, 2024, at 12:01 p.m., Resident 4 was observed lying in bed with bilateral padded half-length bed rails raised. On January 11, 2024, Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included seizures. A review of Resident 4's document titled, Bed Rails, dated October 6, 2023, indicated to use bilateral half bed rails. The assessment did not indicate other alternatives attempted prior to the use bed rails, except pillows. The document did not indicate the reason why the use of pillows was not effective. A review of Resident 4's physician's order, dated November 24, 2023, indicated bilateral padded half-length bed rails for seizure precaution. The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 15, 2023, was conducted two months prior to the bed rail assessment on order for bed rails on October 6, 2023, and the physician's order on November 24, 2023. In addition, the assessment did not indicate Resident 4's size and weight in relation to the dimension of the bed being used. 13. On January 9, 2024, at 12:52 p.m., Resident 28 was observed lying in bed with bilateral padded full-length bed rails raised. On January 11, 2024, Resident 28's record was reviewed. Resident 28 was admitted to the facility on [DATE], with diagnoses which included seizures. A review of Resident 28's physician's order, dated March 27, 2023, indicated bilateral padded full-length bed rails for seizure precaution. A review of Resident 28's document titled, Bed Rails, dated March 24, 2023, indicated to use bilateral half-length bed rails for seizure precaution (different from the physician's order of full-length bed rails). In addition, the document did not indicate other alternatives used prior to the use of bed rails, except the use of pillows. The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 15, 2023, was conducted five months after the physician's order and bed rail assessment for bed rails on March 27, 2023. The document also indicated full-length side rails which is different from the Bed Rails assessment (half- length side rails) completed on March 24, 2023. In addition, the assessment did not indicate Resident 28's size and weight in relation to the dimension of the bed being used. 14. On January 9, 2024, at 12:08 p.m., Resident 30 was observed lying in bed with bilateral padded full-length bed rails raised. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 9 of 28 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 01/11/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm On January 11, 2024, Resident 30's record was reviewed. Resident 30 was admitted to the facility on [DATE], with diagnoses which included epilepsy (a type of brain disorder causing seizures). A review of Resident 30's physician's order, dated October 10, 2023, indicated bilateral padded full-length bed rails for seizure precaution and to keep mattress in place. Residents Affected - Some A review of Resident 30's document titled, Bed Rails, dated November 11, 2023, did not indicate other alternatives used prior to the use of bed rails, except to provide visual and verbal reminders to use the call light. The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 15, 2023, was conducted two months prior to the physician's order on October 10, 2023, and three months prior to the bed rail assessment on November 11, 2023. In addition, the assessment did not indicate Resident 30's size and weight in relation to the dimension of the bed being used. 15. On January 9, 2024, at 12:13 p.m., Resident 40 was observed lying in bed with bilateral padded full-length bed rails raised. On January 11, 2024, Resident 40's record was reviewed. Resident 40 was admitted to the facility on [DATE], with diagnoses which included seizures. A review of Resident 40's physician's order, dated November 22, 2023, indicated bilateral padded full-length side rails for seizure precaution. A review of Resident 40's document titled, Bed Rails, dated November 21, 2023, indicated to use bilateral full-length side rails for seizure precaution. In addition, the document did not indicate other alternatives attempted prior to use of bed rails, except pillows. The document also did not indicate the reason why the use of pillows as alternative was not effective. The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 15, 2023, was conducted three months prior to the physician's order for bed rails on November 22, 2023. The document indicated the assessment conducted was for the use of bilateral half-length side rails which was different from the bed rail assessment and physician's order for full- length side rails. In addition, the assessment did not indicate Resident 40's size and weight in relation to the dimension of the bed being used. 16. On January 9, 2024, at 12:16 p.m., Resident 13 was observed lying in bed with bilateral padded half-length bed rails raised. On January 11, 2024, Resident 13's record was reviewed. Resident 13 was admitted to the facility on [DATE], with diagnoses which included vegetative state. A review of Resident 13's physician's order, dated February 27, 2022, indicated bilateral padded half-length bed rails for seizure precaution. A review of Resident 13's document titled, Bed Rails, dated October 28, 2023, did not indicate other alternatives attempted prior to use of bed rails, except to provide visual and verbal reminders to use the call light. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 10 of 28 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 01/11/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 15, 2023, was conducted two months prior to bed rail assessment on October 28, 2023, and more than a year after the physician's order for bed rails on February 27, 2022. In addition, the assessment did not indicate Resident 13's size and weight in relation to the dimension of the bed being used. On January 10, 2024, at 1:30 p.m., an interview with the Maintenance Director (MTD) was conducted. He stated he conducted the entrapment risk assessment for the use of bed rails which he referred to the document titled Bed System Measurement Device Test Results Worksheet. He stated the entrapment risk assessment was being conducted annually for all the beds with bedrails in the facility. However, he stated the assessment was not specific to the size and weight of the residents using the bed rails, and not done prior to use of the bed rails. On January 11, 2023, at 1:37 p.m., an interview with the Director of Nursing (DON) was conducted. He stated the residents were being assessed for the use of bed rails upon admission. He stated bed rails were used for those residents with seizures and as an enabler for those that were alert. He stated bed rails were being used to keep the low air loss mattress in place and keep the residents from falling out of bed when they cough. He stated the risk for the use of bed rails when the resident coughs may result in the resident hitting either side of the bed rails. He stated this concern could causing discolorations or other injuries for the residents. The DON was not able to answer when the DON was asked if bed rails were to be used to keep low mattress in place was a valid indication to use the bed rails. The DON stated the type of bed rails (quarter, half, or full-length bedrails) were not individualized per resident's needs. He stated the type of bed rails use for the residents were based on the availability of the bed rails that come with the bed. The DON stated all residents were to be assessed for entrapment risk with the use of bed rails annually by the MTD, which he referred to the document titled, Bed System Measurement Device Test Results Worksheet, prior to use of bed rails. He stated the entrapment risk assessment was conducted for the bed itself and not specific to the size and weight of the residents using the bed rails. He also stated they did not use other alternatives, other than the use of pillows, prior to the use of bed rails for the residents. The facility's policy and procedure titled, Proper Use of Bed Rails, dated December 19, 2022, was reviewed. The documented indicated, .It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternatives approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensure correct installation, use, and maintenance of the rails .As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs .Medical diagnosis, conditions, symptoms, and/or behavioral symptoms .Size and weight .The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs .The facility will attempt to use appropriate alternatives prior to installing or using bed rails. Alternatives include .roll guards .foam bumpers .lowering the bed .concave mattress .If no appropriate alternatives are identified, the medical record should include evidence of the following .purpose for which the bed rail was intended and evidence that alternatives were tried and were not successful .Assessment of the resident, the bed, the mattress and rail for entrapment [NAME] (which would include ensuring bed dimensions are appropriate for resident size/weight) .The facility will continue to provide necessary treatment and care to the resident who has bed rails (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 11 of 28 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 01/11/2024 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 0700 in accordance with professional standards of practice and the resident's choice . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 12 of 28 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 01/11/2024 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. Based on observation, interview, and record review, the facility failed to ensure medications were disposed timely according to the facility's policy and procedure, for one of one resident (Resident 40), when one intravenous (IV) antibiotic medication was observed hanging on the IV pole, readily available for use after IV therapy was completed. This failure had the potential for Resident 40 to receive discontinued medication and/or could result in medication administration error. Findings: On January 8, 2024, at 12:17 p.m., one bag of IV medication labeled ertapenem (medication to treat infection) with Resident's 40's name and dated January 6, 2024, at 2:25 p.m., was observed hanging on the IV pole near Resident 40's bed side. On January 8, 2024, at 1:07 p.m., Resident 40 was observed with Registered Nurse (RN) 1. One IV medication labeled ertapenem with the resident's name and dated January 6, 2024, at 2:25 p.m., was observed hanging on the IV pole near Resident 40's bedside. RN 1 stated the ertapenem IV medication contained approximately two milliliters (ml - unit of measurement). In a concurrent record review with RN 1, she stated the IV medication ertapenem for Resident 40 was completed on January 6, 2024, at 2:25 p.m. She stated all completed IV medication should be discarded after the last dose administered and/or when therapy is completed. She further stated leaving the IV medication bag could result in medication errors. On January 11, 2024, at 2:56 p.m., an interview the Director of Nursing (DON) was conducted. He stated the IV ertapenem medication for Resident 40 should have been discarded after it was last administered on January 6, 2024, at around 3 p.m., per facility's policy and procedure. The facility's policy and procedure titled, Intravenous Therapy, dated December 19, 2022, was reviewed. The policy indicated, .The facility will adhere to accepted standards of practice regarding infusion practices .Procedures: Continuous Infusion .discard any used supplies . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 13 of 28 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 01/11/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: Residents Affected - Few 1. [NAME] 2 was unable to accurately verbalized the starting temperature of cool down process for hazardous foods. This failure had the potential to cause foodborne illness, for five (5) out of five (5) residents who received food from the kitchen; and 2. [NAME] 1 served chunks of pureed spinach casserole (pureed foods should be smooth for residents who have difficulty chewing and/or swallowing) during the noon meal on January 10, 2024. This failure had the potential risk of choking, for one out of one resident (Resident 30) who received pureed food from the kitchen. (Cross referred with F805) Findings: 1. On January 8, 2023, at 4:02 p.m., a concurrent interview and record review was conducted with [NAME] 2 (CK) and the Dietary Supervisor (DSS). CK 2 stated the initial/starting temperature required when hot foods would be cooled down was from 130°F. The facility document titled, Cool Down Log, was concurrently reviewed with the DSS and CK 2. The DSS stated the cool down log indicated the initial/starting temperature required when cooling down hazardous hot foods was from 140°F (Foods Cooling is an essential process used in food production to prevent foodborne illness. Bacteria grow best in food in the temperature range 140 °F to 41°F, also referred to as the temperature danger zone. Food must be cooled quickly to minimize bacterial growth. If left out to cool, cooked food can become unsafe to eat in a matter of hours). On January 10, 2023, at 9:34 a.m., an interview with the Registered Dietitian (RD) was conducted. The RD stated the starting temperature during cool down process for hazardous foods was from 140°F. The RD explained if the starting temperature for cooling process started from 130°F, the food was already in the food danger zone which could lead to food borne illness. The RD stated his expectation was for the dietary staff to follow the policy and procedure for the cooling monitor for hazardous foods. A review of the facility's policy and procedure titled, Cooling monitor for Hazardous foods, revised dated May 20, 2020, indicated, .Policy: Food handling rules for cooling hazardous foods should be used by Food and Nutrition or Dining Services department employees. Hazardous foods are defined as: Beans/rice/Pasta, Bean Sprouts, Pies/Pastries, Eggs unpasteurized, Potatoes, Meats/Soy Protein/Drippings used for Sauces or Gravies, Cheese/Whipped Butter, Chicken/Shellfish, Dairy/Non-Dairy Agents, Cut Leafy Greens and Tomatoes, Mayo Mixed Salads, Melons .The food should be cooled from 140 °F to 70 °F within 2 hours and cooled from 70 to 41 °F in an additional 4 hours . A review of the facility's document titled, Job Description Cook, revised dated September 21, 2018, indicated, .Primary Responsibility: Prepared and serves meals according to .monitors methods of food handling, preparation .Specific Responsibilities .Coordinate food preparation and meal service .Monitor temperature of hot .foods through food preparation and service to ensure that established temperature goals are met prior to steamtable transfer . 2. On January 10, 2024, at 11:30 a.m., a concurrent observation and interview was conducted with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 14 of 28 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 01/11/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm [NAME] 1 (CK) and the DSS. She stated the pureed spinach casserole needed to be in a smooth mash-potato like consistency. CK 1 was observed to prepare pureed spinach casserole by placing spinach casserole in a blender and added warm milk to blend. The pureed spinach casserole was observed to have a chunky texture after it was blended. CK1 and the DSS confirmed that was the right consistency of pureed spinach casserole to serve resident on a puree diet. Residents Affected - Few On January 10, 2024, at 12:55 p.m., a concurrent observation and interview was conducted with the RD. The RD stated the pureed diet needed to be prepped in a smooth mash-potatoes like consistency with no lumps and no chunks. The RD further explained if the provided pureed foods had chunks or lumps, the resident could choke, aspirate or had difficulty swallowing the served food. The was observed to taste and test the prepared pureed casserole. The RD stated there were chunks found in the pureed spinach casserole and was not the appropriate texture for puree diet. The RD stated his expectation from the dietary staff was to follow the instructions of the recipe to provide smooth, no chunks, pureed foods. A review of the facility's document titled, Job Description Cook, revised dated September 21, 2018, indicated, . Specific Responsibilities .Coordinate food preparation and meal service .Prepare .serve .main dish .according to .recipes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 15 of 28 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 01/11/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a puree diet (a diet with food texture of smooth pudding-like or smooth mashed potato-like consistency) was prepared and provided, for one of one resident (Resident 30) when the resident received chunks of spinach casserole for lunch on January 10, 2024. This failure placed Resident 30 at risk for aspiration (accidentally inhaling food or liquid into the lungs) and choking. Findings: On January 10, 2024, at 11:30 a.m., during an observation in the kitchen of the puree diet preparation with [NAME] (CK) 1 and the Dietary Supervisor (DSS), CK 1 was observed to grind the cooked spinach casserole in the food processor. The spinach casserole texture was observed to have chunks. In a concurrent interview with CK 1 and the DSS, both stated the texture of the spinach casserole was the right texture for a puree diet. On January 10, 2024, at 12:55 p.m., during a concurrent observation and interview with the Registered Dietician (RD). The RD stated a puree diet needed to be prepared with a smooth mashed potato like texture with no lumps and no chunks. The RD further stated a resident could choke or aspirate if the texture of the puree diet was not prepared correctly. The RD was observed to taste the pureed spinach casserole. The RD stated the pureed spinach casserole was not smooth, had chunks, was very thick and needed more liquid and grinding to achieve the correct puree texture. The RD further stated the pureed spinach casserole did not have the smooth mashed potato-like texture for a puree diet. A review of Resident 30's medical record indicated, Resident 30 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing). A review of Resident 30's physician order, dated October 19, 2023, indicated, .Regular Diet Puree texture . A review of the kitchen Diet Census, on January 10, 2024, indicated, .Resident 30 .Diet order .Regular diet puree texture . A review of the facility' document titled, Pureed Casseroles Recipe, dated August 20, 2018, indicated, .Pureed Casseroles .Place in food processor and process until smooth .If needed, gradually add hot broth or milk .process until smooth in consistency . A review of the facility's policy and procedure titled, Mechanically Altered/Dysphagia Diets, dated September 24, 2018, indicated, .Puree Diet .is designed for people who have severe chewing and/or swallowing problems .All foods are pureed to a smooth pudding-like consistency .Well-cooked pasta .should be pureed to smooth pudding like consistency . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 16 of 28 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 01/11/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review, the facility failed to follow the physician's prescribed diet order, for one of five resident (Resident 36) observed during lunch on January 9, 2024, when Resident 36 did not receive the prescribed portion size during lunch meal. This failure resulted in Resident 36 to receive less calories from small portion, and could potentially result in unplanned weight loss, further compromising the nutritional and medical status of Resident 36. Findings: On January 9, 2024, at 11:50 a.m., a concurrent observation, and record review was conducted with [NAME] 1 (CK). CK 1 was observed to place one scoop of two ounces of meat, mashed potatoes, and peas on Resident 36's plate. Resident 36's meal ticket in the meal tray indicated, Small portions. The facility diet census (a diet list indicated resident's name and the physician's prescribed diet order) provided by the Dietary Supervisor (DSS) on January 9, 2024, indicated Resident 36 was on regular portion. The dietary spread sheet indicated four ounces of meat, mashed potatoes, and peas should be provided for a regular portion diet. On January 9, 2024, at 12:35 p.m., an interview was conducted with CK1. CK 1 stated she served half of regular portions of meat, mashed potatoes and peas to Resident 36 because Resident 36 was on small portion. On January 9, 2024, at 12:45 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated Resident 36 had a physician's order of regular diet. He stated Resident 36 was on regular portion and should have received regular portion every meal. On January 10, 2024, at 9:33 a.m., a concurrent interview and record review was conducted with the Dietary Supervisor (DSS). The DSS stated nursing informed her Resident 36 requested for small portion diet. Reviewed Resident 36 diet requisition (diet communication slip between nursing and dietary) with the DSS. Resident 36's diet requisition indicated, small portion, dated on 10/5/23 (October 5, 2023). The DSS stated if a resident requested small portion, it needed to get a physician ordered for small portion. On January 10, 2024, at 9:38 a.m., a concurrent interview and record review was conducted with the Registered Dietitian (RD). The RD stated if a resident requested a small portion, it needed to have a physician order prior to serving to the resident. The RD further explained if a resident had a physician ordered with regular portion and received small portion from dietary, weight loss could happen due to resident receiving less calories with small portion. The RD stated she was unaware Resident 36 received small portion from dietary since October 5, 2023. Reviewed Nutrition Progress Note, dated October 12, 2023, the RD stated he recommended regular portions with all meals for Resident 36. The RD acknowledged the Interdisciplinary team (IDT-a group of health care professionals all working toward a common goal) needed to be involved to collaborate regarding small portion per Resident 36 request. A review of the facility's policy and procedure titled, Small Portions, revised dated December 15, 2016, indicated, .Small portions may be requested by residents who have small appetites or when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 17 of 28 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 01/11/2024 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 0808 regular portions seem overwhelming and must be physician ordered . Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Provision of Physician Ordered Services, revised May 15, 2023, indicated, .The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality .Dietary modifications: Dietary staff will implement .dietary modifications as prescribed by the physician . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 18 of 28 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 01/11/2024 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 Residents Affected - Some 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 food was served and prepared in a sanitary condition and in accordance with professional standards for food service safety practice when: 1. There were multiple areas in the kitchen, kitchen equipment, and food storage areas that were not clean; 2. The kitchen floor was not clean and had pores, indentation, cracked, and missing flooring tiles; and 3. The resident refrigerator had multiple unlabeled food items. These failures had the potential to place residents at risk for foodborne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death. Findings: 1. On January 8, 2024, at 10:10 a.m., during a walk-through observation inside the kitchen with the Dietary Supervisor (DSS), the following were observed: - The storage pitcher shelves and multiple spice container lids were observed to have a whitish-gray debris; - The fire extinguisher metal bracket to the right top corner area of the coffee machine was observed to have hair like debris; - The walls at the right side and behind the coffee machine were observed to have black hair like debris; - The ceiling above the workstation was observed to have gray-brown hair like debris; - The pipes and ventilation on the hood above the stove was observed to have grayish hair like debris; - The can opener in front of the stove was observed with dry, black goo-like residue and hair like debris; - The reach in refrigerator #1 door gasket was observed with black grime and the right upper corner air ventilation inside the refrigerator was observed to have grayish hair like debris; and - The reach in refrigerator #2 door was observed with black goo-like grime. On January 8, 2024, at 10:23 a.m., during an interview with the DSS, she stated the whitish-gray debris on the storage pitcher shelves and on the lids of multiple spices were dust. The DSS further stated there should be no dust on those areas. The DSS stated the kitchen areas should have been cleaned and wiped to prevent cross contamination of the dust particles with food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 19 of 28 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 01/11/2024 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 On January 8, 2024, at 10:35 a.m., during an interview with the DSS, she stated the hairlike debris on the extinguisher, the blackish hair like debris on the walls to the right side and behind the coffee machine and the gray-brown hair like debris above the workstation were accumulated dust fibers. The DSS stated the dust fibers should not be there and those areas should have been cleaned and wiped to prevent cross contamination of the dust particles with food. Residents Affected - Some On January 8, 2024, at 11:06 a.m., during an interview with the DSS, she stated the hood ventilation and pipes had dust fibers, and the can opener had hair, and the black goo was dried grease. The DSS stated the hood ventilation and pipes, and the can opener should have been cleaned more frequently to prevent food cross contamination and foodborne diseases. On January 8, 2024, at 11:22 a.m., during an interview with the DSS, she stated the air ventilation inside Refrigerator #1 was covered with dust and the refrigerator gasket had black grime. The DSS further stated it's not supposed to be there, and it should have been cleaned to prevent cross contamination on food and prevent foodborne diseases. On January 8, 2024, at 11:36 a.m., during an interview with the DSS, she stated, the black-goo debris inside refrigerator #2 door was mold. The DSS further stated mold should not be there and it should have been cleaned to prevent food borne diseases and for resident safety. On January 10, 2024, at 9:38 a.m., during an interview with the Registered Dietician (RD), he stated, dust on shelves, refrigerator, refrigerator vents and refrigerator fans or on any food preparation area should not be there. The RD further stated the kitchen should be free of debris and dust to prevent cross contamination of the food that can lead to foodborne diseases. A review of the facility policy and procedure titled, Shelves and Other Surfaces, dated August 31, 2018, indicated, .Keep fans clean and free of dust particles . According to the Federal and Drug Administration (FDA) Food Code 2022, .4-602.13 Nonfood-Contact Surfaces .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 January 8, 2024 at 11:10 a.m. during the initial kitchen observation with the DSS, the following were observed of the kitchen floor: - The kitchen floors were observed with black grime; - The floor on the dirty area of the kitchen was observed to have pores, indentations, not smooth, with grease and black grime build up, and with approximately 14 tiles cracked and chipped; - The floor under the dish wash station was observed to have two (2) missing tiles and with brown-yellowish goo like grime; and - The flooring on the dry storage room had one cracked tile and two missing tiles. During a concurrent interview with the DSS, he stated the kitchen floors had grime and needed to be deep cleaned. The DSS further stated the floor in the dirty area of the kitchen was not smooth, had indentations and needed to be replaced and was very dirty. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 20 of 28 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 01/11/2024 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 Residents Affected - Some On January 8, 2024, at 3:40 p.m. during an interview with the DSS and the Maintenance Director (MTD), both stated, the dry storage room floor had one (1) tile cracked and broken and there were two (2) missing tiles, and the floor was bare. On January 8, 2024, at 3:47 p.m. during an interview with MTD, he stated the floor under the dish wash station had two (2) missing tiles and is bare concrete. The MTD further stated there was grime build-up and the floor was very dirty. The MTD stated kitchen flooring should not be bare, cracked, or chipped, and should be clean with no grime build-up. The MTD further stated bacteria can grow if the floors are bare or not intact and not clean, it can cause sickness. On January 10, 2024, at 9:38 a.m., during an interview with the RD, he stated the kitchen floors should be clean, with a smooth surface, free of cracks and chipping to prevent build up and bacterial growth that can potentially cross contaminate the food items that were being prepared in the kitchen. A review of the facility policy and procedure titled, Shelves and Other Surfaces, dated August 31, 2018, indicated, .Clean floor drains and keep free of debris . A review of the facility policy and procedure titled, Floors/Floor Mats/ Baseboards, dated August 31, 2018, indicated, .Assure drains are scrubbed and free of debris . A review of the facility policy and procedure titled, Food Storage, dated August 31, 2018, indicated, .The walls, ceilings and floor should be maintained in good repair and regularly cleaned . A review of the Federal and Drug Administration (FDA) Food Code 2022, .6-201.12 Floors, Walls, and Ceilings, Utility Lines .Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned .Requirements and restrictions are intended to ensure that regular and effective cleaning is possible, and that insect and rodent harborage is minimized . 3. On January 8, 2024, at 4:32 p.m., during an observation of the resident refrigerator located in the activity room with Certified Nursing Assistant (CNA) 1. The resident refrigerator was observed to have the following foods not labeled and dated with the resident's name and room number: - One (1) 20 oz. (ounce - unit of measurement) bottle of ketchup; - Eight (8) boost glucose control drink 8 oz; - One (1) 11 oz protein shake; - One (1) 6 oz. yogurt; and - Seven (7) food containers containing green salsa (two), cheese cake, brown ground food, rice with meat, apple sauce, and soup. During a concurrent interview with CNA 1, she stated the process on storing resident food was for the food needed to be labeled and dated with the resident's name and room number. CNA 1 further stated the food was only allowed to be kept in the resident's refrigerator for three days and it has to be discarded after. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 21 of 28 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 01/11/2024 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 Residents Affected - Some CNA 1 stated the bottle of ketchup, boost glucose control drinks, protein shake, yogurt, and the seven (7) food containers were not labeled and dated with the resident's name and room number. CNA 1 further stated she did not know who the food belongs to or when and how long the food had been in the refrigerator and the food might be spoiled. CNA 1 stated all the food items in the resident's refrigerator should have been discarded for resident safety and to prevent foodborne disease. On January 10, 2024, at 9:38 a.m., during an interview with the RD, he stated the food in the resident's refrigerator should be labeled and dated with the resident's name and room number, when the food was received. The RD further stated unlabeled foods can cause foodborne disease since there was no way of knowing how long the food was in the refrigerator or who the food belongs to. A review of the facility policy and procedure titled, Food: Safe handling for Foods from Visitors, dated September 13, 2023, indicated, .When food items are intended for later consumption .Label foods with the resident name and the current date .Daily monitoring for refrigerated storage duration and discard of any food items that has been stored for > (greater than) 7 (seven) days . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 22 of 28 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 01/11/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to ensure appropriate infection control were followed when: Residents Affected - Many 1. The facility's water system was not tested for Legionella (a bacteria whichcould cause a serious type of pneumonia [lung infection]) and other waterborne diseases. This failure had the potential to place residents at risk for health complications related to Legionella; and 2. Three suction tubings (flexible tubes used for the removal of secretions) and one Yankauer (a tool used to suction oral secretions) were not dated, for three of three residents (Residents 2, 17 and 34). In addition, two Yankauers were not changed according to the facility's policy and procedure, for two of three residents (Residents 1 and 17.) This failure had the potential to cause an increased risk for respiratory infection for Residents 2, 17 and 34. Findings: 1. On January 10, 2024, at 11:06 a.m., an interview with the Maintenance Director (MTD) was conducted. The MTD stated the facility had a water management program which included conducting water sampling analysis for Legionella. The MTD stated there was no water sampling analysis nor assessment done for the facility for years 2020, 2021, 2022, and 2023. The MTD stated had contracted a company to conduct the water sampling analysis on December 11, 2023, but the company didn't come. The MTD stated he should have contacted another company to perform the water analysis for the facility. On January 11, 2024, at 4:18 p.m., an interview was conducted with the Infection Preventionist Nurse (IP). The IP stated water sampling had not been conducted in the facility prior to January 11, 2024. In addition, the IP stated the facility's policy on water management indicated water analysis for Legionella should be done annually. On January 11, 2024, at 5:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the facility did not conduct annual water analysis for Legionella according to their policy and procedure. A review of the undated facility document titled, Legionella Water Management Program, indicated, . CDC elite legionella testing will be performed quarterly . According to the article published by Centers for Disease Prevention and Control (CDC) titled, Water Management in Healthcare Facilities, dated March 25, 2021, indicated, .CDC encourages healthcare facilities .to develop and implement comprehensive water management programs. Water management programs can help reduce the risk for Legionella growth and transmission .Water management programs should therefore be monitored for their efficacy in reducing the risk for a variety of pathogens . 2. On January 11, 2024, at 2:05 p.m., Resident 2 was observed lying in bed with a tracheostomy (a small, surgical opening through the skin into the windpipe) tube connected to a ventilator (a machine that helps people breathe when they cannot breathe naturally). The suction tubing was observed not to be dated and the Yankauer tip was dated January 1, 2024 (10 days from observation date). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 23 of 28 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 01/11/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On January 11, 2024, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included respiratory failure (a serious condition that makes it difficult to breathe on your own), and dependence on ventilator. On January 11, 2024, at 2:10 p.m., Resident 34 was observed lying in bed with a tracheostomy tube connected to a ventilator. The suction tubing and the Yankauer tip were not dated. On January 11, 2024, Resident 34's record was reviewed. Resident 34 was admitted to the facility on [DATE], with diagnoses which included respiratory failure, and tracheostomy. On January 11, 2024, at 2:21 p.m., Resident 17 was observed lying in bed with a tracheostomy tube connected to a ventilator. The suction tubing was not dated and the Yankauer tip was dated December 24, 2023. On January 11, 2024, Resident 17's record was reviewed. Resident 17 was admitted to the facility on [DATE], with diagnoses which included with diagnoses which included respiratory failure, tracheostomy, and dependence on ventilator. On January 11, 2024, at 2:15 p.m., a concurrent interview and observation for Residents 2 and 34 were conducted with Respiratory Therapist (RT) 1. Resident 2 was non-verbal and was observed in bed with tracheostomy tube connected to a ventilator. In a concurrent interview with RT 1, he stated Resident 2's suction tubing was not dated and the Yankauer tip was dated January 1, 2024. Resident 34 was non-verbal and was observed in bed with a tracheostomy tube connected to a ventilator. In a concurrent interview with RT 1, he stated Resident 34's suction tubing and the Yankauer tip were not dated. RT 1 further stated the suction tubings should be dated when changed every three days and the Yankauer tips should have been changed every Monday (January 8, 2024). On January 11, 2024, at 2:30 p.m., a concurrent interview and observation for Resident 17 was conducted with RT 2. Resident 17 was non-verbal and observed in bed with a tracheostomy tube connected to a ventilator. In a concurrent interview with RT 2, he stated Resident 17's suction tubing was not dated and the Yankauer tip was dated December 24, 2023 (18 days prior to observation date). RT 2 further stated the Yankauer tip should be changed every Monday and if not changed can potentially cause infection when used. The undated facility's policy and procedure titled, Changing the Yankauer, was reviewed. The policy indicated, .all Yankauers will be changed every week . The undated facility's policy and procedure titled, Changing Suction Canisters, was reviewed. The policy indicated, .all suction canisters with tubing will be changed every week . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 24 of 28 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 01/11/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the pneumonia (lung infection) vaccine was offered, for one of five residents reviewed for immunization (Resident 35). Residents Affected - Few This failure had the potential for an increased risk for Resident 35 to acquire pneumonia. Findings: On January 10, 2024, Resident 35's record was reviewed. The facility document titled, admission Record, indicated Resident 35 was admitted to the facility on [DATE], with diagnoses which included respiratory failure (a serious condition that makes it difficult to breathe on your own), tracheostomy (a small, surgical opening through the skin into the windpipe), and dependence on ventilator (a machine that helps people breathe when they cannot breathe naturally). The document indicated Resident 35 was [AGE] years old. In addition, the document indicated Resident 35's family member as the responsible party to make healthcare decisions for the resident. A review of Resident 35's Pneumococcal Vaccination Record located under the Immunizations tab of her electronic health record (EHR- a digital version of a patient's paper chart) indicated Resident 35 received Prevnar 13 (PCV13 - a pneumococcal vaccine) on January 27, 2016. On January 10, 2024, at 4:09 p.m., a concurrent interview and record was conducted with the Infection Preventionist (IP). The IP stated residents were screened for pneumonia immunization status upon admission. The IP stated the resident or resident representative would be offered to receive the pneumonia vaccine if the resident did not receive the complete series of pneumonia vaccines. The IP stated Resident 35 received PCV 13 on January 27, 2016. The IP further stated Resident 35 should have been offered to receive pneumonia vaccine 20 (PCV20 - a pneumococcal vaccine) upon admission. The facility's policy, and procedure titled, Pneumonia Vaccination, dated May 2009, was reviewed. The policy indicated, . Upon admission the resident will be assessed for eligibility to receive the pneumococcal vaccine and when indicated, provided the vaccination within 60 days of admission to the facility pneumococcal vaccination protocol: an individual received the vaccine prior to reaching the age of 65 and more than 5 years had passed .Administration of the pneumococcal vaccine is made in accordance with current Center for Disease control and Prevention (CDC) recommendation at the time of the vaccination . According to the article published by Centers for Disease Control and Prevention (CDC) titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, dated September 22, 2023, .adults 19 through [AGE] years old with certain risks conditions .only received PCV13 . give 1 (one) dose of PCV20 .the PCV20 dose should be given at least 1 (one) year after PCV13. When PCV 20 is used, their vaccines are then complete . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 25 of 28 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 01/11/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure, two (2) microwave ovens, six (6) refrigerator shelves, six (6) dry storage room shelves, one (1) refrigerator gasket, and one (1) freezer gasket were maintained in a safe operating condition. Residents Affected - Some These failures had the potential to place residents at risk for foodborne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death. Findings: On January 8, 2024, at 11:12 a.m., during the kitchen observation with the Dietary Supervisor (DSS), the top area of the microwave oven was observed to have six (6) open circular areas with brown-copper discoloration and peeled paint. In a concurrent interview with the DSS, she stated, the microwave oven paint is melting, and the six open circular areas were with rust. The DSS further stated the rust and paint could fall on the residents' food and cause contamination. The DSS stated the microwave oven should have not been used for resident safety and to prevent foodborne illness. On January 8, 2024, at 11:22 a.m., during the kitchen inspection with the DSS, the reach-in refrigerator #1, there were 6 shelves observed to have brown-copper discoloration. In a concurrent interview with the DSS, she stated the brown-copper discoloration on the six (6) shelves inside the refrigerator were rust. The DSS further stated rust should have not been there and all shelves needed to be free of rust for food safety and to prevent food cross contamination. On January 8, 2024, at 11:36 a.m., refrigerator #2 door gasket (rubber piece that lined on the door to prevent cool air sip out) was observed torn. In a concurrent interview with the DSS, she stated the refrigerator gasket was torn. The DSS further stated it should not be like that, the refrigerator cannot close properly and cannot keep the appropriate temperature to prevent foodborne diseases if the gasket was torn. On January 8, 2024, at 11:46 a.m., the freezer door gasket was observed not intact. In a concurrent interview with the DSS, she stated the freezer gasket was broken and torn. The DSS further stated it should not be like that, the freezer cannot close properly and cannot keep the appropriate temperature to prevent food borne illness if the gasket was broken. On January 8, 2024, at 11:50 a.m., during an observation of the dry storage room, there were six (6) metal rack shelves observed to have brown-copper discoloration. On January 8, 2024, at 3:40 p.m., during a concurrent observation and interview with the DSS and the Maintenance Director (MTD), both stated the six (6) metal rack shelves in the dry storage room were rusted. The DSS further stated rust should have not been there and all shelves should be free of rust for food safety and to prevent food cross contamination. On January 8, 2024, at 4:32 p.m., during a concurrent observation and interview inside the activity room with Certified Nursing Assistant (CNA) 1, the microwave was observed to have brown-copper discoloration with peeled paint inside the front bottom area and the inside left upper top corner area of the microwave oven. In addition, the inside top middle area of the microwave oven was observed to have five (5) paint bubbles. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 26 of 28 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 01/11/2024 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 0908 Level of Harm - Minimal harm or potential for actual harm In a concurrent interview with CNA 1, she stated the microwave oven was being used to warm resident's food during the nigh) shift. CNA 1 further stated the microwave was old, the paint bubbled and peeled inside the microwave, and the brown-copper discoloration was rust. CNA 1 stated rust and peeled paint should not be there and could fall on the resident's food when heated up. CNA 1 further stated this was not safe, and could cause food contamination and foodborne disease. Residents Affected - Some On January 10, 2024, at 9:38 a.m., during an interview with the Registered Dietician (RD). The RD stated rust and peeled paint, or any kitchen equipment with decomposition should have not been used in the kitchen. The RD stated rust and peeled paint was a food safety hazard that could fall into food and could cause cross contamination and foodborne disease. The RD stated torn gaskets had the potential to not be able to keep the refrigerator or freezer at right temperature zone which could cause food borne illness. The RD expectation was all equipment used in the kitchen was in the safe operation condition with free of rust and peeling paint. A review of the facility policy and procedure titled, Operation and Sanitation, dated August 31, 2018, indicated, .When equipment is not functioning correctly . request repair of equipment and follow up to assure repair work is completed . A review of the undated facility policy and procedure titled, Equipment Maintenance, indicated, .The maintenance department is responsible for inspecting equipment annually, or more often .to ensure proper working order . According to the Federal and Drug Administration (FDA) Food Code 2022, .FOOD-CONTACT SURFACES of EQUIPMENT .shall be .to have a smooth, easily cleanable surface and .Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition .Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 27 of 28 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 01/11/2024 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. Based on observation, interview, and record review, the facility failed to provide the required bedroom space measuring at least 80 square feet per resident, in 15 resident rooms (Rooms: 1, 2, 3, 4, 5, 6, 7, 8 , 11, 12, 14, 15, 16, 17, and 18). Findings: On January 11, 2024, at 11:00 a.m., an interview was conducted with the Director of Nursing (DON) regarding the room sizes for resident rooms 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 14, 15, 16, 17, and 18. The DON stated the rooms did not meet the space requirement of at least 80 square feet per resident in the above mentioned resident rooms. The DON stated the facility has a waiver for the rooms. During the survey dates January 8, 9, 10, and 11, 2024, the above listed rooms were observed at different times of the day. There were no adverse effects that impacted the quality of life of the residents who resided in the rooms as observed during the survey dates. On January 11, 2024, the DON provided the request for room waivers for Rooms 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 14, 15, 16, 17, and 18. The survey team recommends the room variance to continue, provided the health and safety of the residents who reside in the above-mentioned rooms, are not adversely affected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055542 If continuation sheet Page 28 of 28