Health inspection·July 3, 2023

F 0602 One saline spray Level of Harm - Minimal harm or potential for actual harm One Calazine barrier cream (used to treat and prevent of diaper rash and minor skin irritations) One Cavilon barrier cream (a cream used to protect intact or damaged skin from irritation) Residents Affected - Few Two gray slips on shoes One pink basin One toothbrush and one toothpaste One comb One lotion and one body wash One tan grip sock A review of Resident 1 ' s Resident Theft and Loss Report dated 6/29/23, indicated Resident 1 ' s missing clothes: 1.Light gray grip socks 2. [NAME] undershirt 3.Tan grip socks 4. One pair blue pajama bottom knit/drawstring 5. One gray and blue striped t-shirt 6.One pair purple grip socks 7. One pair gray grip sock A review of Resident 1 ' s Resident Inventory of Personal Effects, dated 4/21/23, indicated the following personal items were added: one light gray grip socks, one gray beanie, one gray button pajama bottoms, one yellow spiral notebook, one fabric case of colored pencils, and one travel tic-tac-toe game (metal case) in the inventory list. A review of Resident 1 ' s Resident Inventory of Personal Effects dated 5/3/23, indicated additional personal items were added: one long brown sleeve shirt with collar, and was signed in the inventory list. During an interview on 7/3/23 at 9:47 AM, Licensed Vocational Nurse (LVN) 3 stated Resident 1 was discharged on 6/24/23, (Saturday) and the resident was picked up by the family. LVN 3 stated there were no issues regarding discharge except for the missing clothes. LVN 3 stated socks and other clothes were missing in Resident 1 ' s bags. The Resident Inventory Personal Effects was not signed and acknowledgement upon discharge. LVN 3 stated he was not sure if the issue for missing clothes was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 2 of 8 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 555796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Care Center 4800 Delta Avenue Rosemead, CA 91770 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 0602 resolved since he was not working/off the following days. Level of Harm - Minimal harm or potential for actual harm The SSD stated she does not have the description of the missing items. The SSD stated the issue of missing clothes were not addressed earlier since she just read the discharged summary and that the inventory list was not signed on 6/30/23 before the resident was discharged from the facility. The SSD stated that it was the facility ' s policy and procedure (P&P) that missing personal belongings including resident ' s clothes should be reported to the SSD, verify what was missing and if cannot find it, should be replaced. The SSD stated resident and/or family members should fill out and sign personal belongings inventory list upon resident ' s admission, and if there were additional belongings, an additional form should be filled out by resident and/or family member, to be completed by certified nurse assistants (CNA) and licensed nurses. Residents Affected - Few During an interview on 7/3/23 at 1:52 PM, the Director of Nursing (DON) stated she interviewed LVN 3 and she was notified that Resident 1 ' s personal belongings inventory list was not signed prior to being discharged due to some clothes and item missing. The DON stated normally the staff informs the SSD immediately of missing personal items. The DON was unable to answer when asked when the SSD was informed about Resident 1 ' s missing item and why the issue was not acted upon immediately. The DON stated when resident ' s clothes were missing, the issue will be coordinated with the staff working in the laundry, will continue looking and if cannot be located, will reimburse the resident and or the family. During an interview on 7/3/23 at 2:22 PM, FM 1 stated that she brought up the issue of Resident 1 ' s missing personal items to LVN 3 during discharge. Resident 1 ' s personal belongings inventory list was not signed during discharge but gave a list of missing items to LVN 3 but no one called her regarding the issue until present day (7/3/23). During an interview on 7/3/23 at 2:40 PM, Maintenance Supervisor (MS) stated CNAs would put resident ' s names in a clear bag with clothes, then after washing, laundry staff will deliver the clean clothes to resident ' s rooms. The MS stated if there were no name in the bag, laundry staff will ask around, and if no one claims the missing clothes, will keep it for six months and wait for someone to claim the missing clothes. The MS stated if the resident or family reported that there were missing personal clothes, laundry staff including the MS will follow up, ask for the clothe description, look for it and if unable to locate, would report to the SSD. During an interview on 7/3/23 at 2:53 PM, the Assistant Director of Nursing (ADON) stated during resident ' s admission, staff will go over with the inventory list with the resident, call the family and would tell them what belongings came with the resident. The ADON stated, if the family came in with the resident, staff would go over with the inventory list with them, document, and resident and/or family will sign the inventory list. If there were missing clothes, nurse will let the ADON and DON know, then they will discuss in the standup meeting every day and the SSD will follow up on it. The ADON stated, upon discharge, resident and/or family will go through the inventory list, resident and family would sign acknowledging receipt of the belongings. The ADON stated if some items were missing, will notify the SSD and document. The ADON stated, normally staff will communicate with, SSD, ADON and DON the issue immediately, and if during weekend, should be communicated on Monday. The ADON stated the issue of Resident 1 ' s missing clothes and items should be addressed right away. The ADON stated residents should be free from misappropriation of property. A review of facility ' s P&P titled Inventory of Personal Belongings revised in 1/2023, indicated It is the policy of the facility to take reasonable steps to protect the personal property of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 3 of 8 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 555796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Care Center 4800 Delta Avenue Rosemead, CA 91770 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete residents. The P&P indicated Upon discharge of a resident from the facility, the resident or responsible party shall date and sign the Certification of Receipt on Discharge section of the form in conjunction with a staff nurse in order to certify that the resident's personal belongings and personal effects were received. During a review of facility ' s P&P titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment revised in 11/28/22, indicated It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. Event ID: Facility ID: 555796 If continuation sheet Page 4 of 8 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 555796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Care Center 4800 Delta Avenue Rosemead, CA 91770 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement fall prevention interventions for three (3) of nineteen (19) sampled residents (Resident 1, 2, and 3) who were at risk for fall by failing to ensure bed alarms (position change alarms; are alerting devices intended to monitor a resident's movement were functional and working. These deficient practices had the potential to cause fall accident that can result to injury or harm. Findings: A review of Resident 1's admission Record indicated the resident was initially admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses that included dementia (group of thinking and social symptoms that interferes with daily functioning), abnormalities of gait (person's manner of walking) and mobility, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment id daily life). A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 4/23/23, indicated Resident 1 had a severe impairment in cognition (ability to understand and reason). The MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 1 had a bed and chair alarm (physical or electronic device that monitors resident movement and alerts the staff when movement is detected) used daily. A review of Resident 1's Physicians Order Sheet for the month of June 2023 indicated Resident 1 may have sensor pads in bed and wheelchair every shift to remind the resident not to get up unassisted. A review of Resident 1's care plan for fall, dated 5/23/23, indicated Resident 1 had an actual fall with an intervention to place sensor pad in bed and wheelchair for safety precaution (measure taken beforehand to prevent harm.) A review of Resident 1's Fall Risk Evaluation dated 5/25/23, indicated Resident 1 was high risk for fall. During an interview on 6/27/23 at 11 AM, Certified Nurse Assistant (CNA) 3 stated during admission, licensed nurses are supposed to inform the CNAs. If residents need a bed or chair alarm, CNAs need to check and make sure that bed and chair alarms were working and functioning. CNA 3 stated bed alarms should always work and functioning. CNA 3 stated Resident 1 does not know how to a use call light, CNA 3 stated Resident 1 fell one time when Resident 1 went to his bed from the wheelchair without asking for assistance. CNA 3 stated during the fall incident, Resident 3 had an alarm on his bed but not on his wheelchair. 2. During an observation on 6/27/23 at 10:13 PM, Resident 2 was observed in bed, two Physical Therapy Aide (PTA) were at the bedside assisting Resident 2 transfer from bed to wheelchair. A bed alarm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 5 of 8 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 555796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Care Center 4800 Delta Avenue Rosemead, CA 91770 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was placed on the resident's bed, but no sound or alarm went off or heard when the resident stood up during the transfer. A review of Resident 2's admission Record indicated the resident was initially admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), reduced mobility, and essential hypertension (high blood pressure). A review of Resident 2's MDS, dated [DATE], indicated Resident 1 had an intact cognition (ability to understand and reason). The MDS indicated Resident 2 required extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 2 had a bed and chair alarm used daily. A review of Resident 2's Physicians Order Sheet for the month of June 2023 indicated Resident 2 may have sensor pads in bed and wheelchair every shift to remind the resident not to get up unassisted. A review of Resident 2's care plan for fall, dated 6/17/23, indicated Resident 2 was at risk for fall related to decrease in bed mobility, Parkinson's disease, cerebral vascular accident (CVA-stroke; an interruption in the flow of blood cells in the brain), rheumatoid arthritis (RA-chronic inflammatory disorder affecting many joints, including those in the hands and feet) with an intervention to place sensor pad in bed and wheelchair for safety precaution. A review of Resident 2's Fall Risk Evaluation dated 6/15/23, indicated Resident 2 was high risk for fall. During a concurrent observation of Resident 2's bed alarm on unoccupied bed and interview with Certified Nurse Assistant (CNA) 2 in 6/27/23 at 10:33 AM, CNA 2 stated that she turned on the bed alarm while talking to the surveyor but was turned off prior to the interview. CNA 2 stated sometimes when the staff moves the bed, the alarm disconnects. CNA 2 stated bed alarms should always be turn on for resident's safety, to prevent fall and injury. CNA 2 stated bed alarm was one of the fall precaution interventions. 3. During an observation of Resident 3's bed alarm and interview with CNA 1 on 6/27/23 at 10:22 AM, CNA 1 stated that the bed alarm's light was turned off. CNA 1 stated after troubleshooting several times, Resident 3's bed alarm was still not working so she needed to inform the facility's maintenance staff. CNA 1 stated when residents get agitated, change position, or tried to get out of bed, the bed alarm will sound, alerting the staff so they can come to the room and check the residents. CNA 1 stated bed alarms were used for fall risk residents for safety. During an interview on 6/27/23 at 10:28 AM, Licensed Vocational Nurse (LVN 1) stated that Resident 3's current bed alarm was not working and needed to be replaced. LVN 1 stated Resident 3 was confused and does not know how to use a call light button. LVN 1 stated Resident 3 and other fall risk residents need bed alarm for safety reasons, to prevent residents from falling, by alerting staff when residents try to get out of bed without assistance. A review of Resident 3's admission Record indicated the resident was initially admitted to the facility on [DATE], with diagnoses that included reduced mobility, essential hypertension, and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 6 of 8 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 555796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Care Center 4800 Delta Avenue Rosemead, CA 91770 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 3's MDS, dated [DATE], indicated Resident 1 had a severe impairment in cognition. The MDS indicated Resident 3 required extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 3 had a bed and chair alarm used daily. A review of Resident 3's Physicians Order Sheet for the month of June 2023 indicated Resident 3 may have sensor pads in bed and wheelchair every shift to remind the resident not to get up unassisted. A review of Resident 3's care plan for fall, dated 3/18/23, indicated Resident 3 was at risk for falls related to Resident 3's history of fall, loss of balance, generalized weakness, CVA, glaucoma (a group of eye diseases that can cause vision loss and blindness) with an intervention to place sensor pad in bed and wheelchair for safety precaution. A review of Resident 3's Fall Risk Evaluation dated 4/25/23, indicated Resident 3 was high risk for fall. During an interview on 6/27/23 at 11:44 AM, LVN 2 stated fall risk precaution interventions include placing bed alarm, chair alarm, floor mats, yellow wrist band, etc. LVN 2 stated licensed nurses should monitor the bed and chair alarm every shift (7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM) and make sure alarms were always working. LVN 2 stated if bed and chair alarms needed to be in good working order. LVN 2 stated majority of the facility's residents had history of fall, thus, uses alarms for safety. LVN 2 stated if residents need alarm on both bed and chair, must use different alarms, not shared. During a concurrent interview with Minimum Data Sheet Coordinator (MDS) 1 and MDS 2 and record review of Residents 1, 2, and 3's Medication Administration Record (MAR) on 6/27/23 at 12:27 PM, MDS 1 stated licensed nurses must monitor bed and chair alarms for placement and to check if working every shift and must be documented in MAR. MDS 2 stated that the bed and chair alarm monitoring in MAR on 6/16/23 and 6/18/23, night shift, were not signed by the licensed nurses. During an interview on 6/27/23 at 1:30 PM, Maintenance Supervisor (MS) stated staff should test and check if the alarms were working before placing them on resident's bed or wheelchair. MS stated bed and chair alarms should also be checked for batteries frequently. MS stated there were new alarms available in the nurse's station and accessible to staff if they needed to be replaced. During a concurrent interview with Registered Nurse (RN) 1 and record review of Resident 1, 2, and 3's Fall Risk Evaluation record, RN 1 stated Resident 1,2 and 3's fall risk evaluation score was 11 and above, meaning Residents 1,2 and 3 were all high risk for fall. RN 1 stated fall risk evaluation of 10 and above means high fall risk. During an interview on 6/27/23 at 2:24 PM, the Director of Nursing (DON) stated bed and chair alarms should be check by everyone including department heads, nurses, and licensed nurses will monitor the bed and chair alarm placement. The DON stated monitoring of bed and chair alarm placement, functioning was part of the physician's order, thus, should be monitored and documented/signed for acknowledgement. The DON stated alarms were devices to alert for resident's fall, one of the fall interventions for high risk for fall residents and has to be always working and functioning. A review of facility's policy and procedures (P&P) titled Fall Management System revised in January 2022, indicated It is the policy of this facility to provide an environment that remain as free of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 7 of 8 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 555796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Care Center 4800 Delta Avenue Rosemead, CA 91770 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 0689 accident hazards as possible. Level of Harm - Minimal harm or potential for actual harm A review of facility's P&P titled Resident Assessment revised in January 2023, indicated Residents with high risk factors identified on the fall risk evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the residne4t at risk. Interventions may include low bed/bed in lowest position, sensor alarm, floor mats, toileting program, 1:1 supervision, etc. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 8 of 8