Health inspection·October 25, 2023

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 2's Order Summary Report, dated 8/26/2023, indicated the Resident 1's full name, date of birth , diagnoses and list of medications the resident was prescribed. A review of Resident 2's admission Record indicated that the resident was admitted to the facility on [DATE] with diagnoses of, but not limited to, dysphagia (difficulty swallowing), history of falling, hearing loss, and rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 8/17/2023, indicated the resident had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making. The MDS indicated the resident required limited to extensive assistance on staff for activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). The MDS indicated Resident 1 required extensive assistance with one person for ADLs. A review of Resident 2's Discharge Summary and Post-Discharge Plan of Care dated 8/28/2023, indicated that Resident 2 was discharged to home. During an interview on 10/24/2023 at 12:50 pm, the Director of Nurses (DON) stated that on 8/28/2023, there were two residents that were leaving the facility at around the same time. The DON stated that Resident 1 had a change of condition and was being transferred to the acute hospital for further evaluation, while Resident 2 was being discharged to home with family. The DON stated that when Resident 2 was discharged to home, Resident 1's discharge paperwork was accidentally given by the licensed nurse to Resident 2's family. During an interview on 10/24/2023 at 2:40 pm, the Administrator (ADM) stated that two residents were leaving the facility at around the same time, on 8/28/2023. The ADM stated that Resident 1 was leaving the facility via 911 emergency services to the acute hospital and Resident 2 was going home with family. The ADM stated Resident 2 accidentally received Resident 1's medication list, which included Resident 1's full name, date of birth , diagnoses and medications prescribed. The ADM stated that the facility became aware of the breach when a third party that conducts satisfaction interviews for the facility reported to the facility that during the satisfaction interviews, Resident 2's family disclosed that they received records with information that was not for Resident 2. The ADM stated she retrieved the documents from Resident 2's family (Family 2) and notified the family of Resident 1 (Family 1). The ADM stated a written notification was provided to the resident's families on 9/14/23. During an interview on 10/24/2023 at 3:15 pm, of Family 1 (Resident 1's family), Family 1 stated that she was informed that Resident 1's private information had been accidentally given to Family 2 (Resident 2's family). During an interview on 10/24/2023 at 3:30 pm, Licensed Vocational Nurse (LVN 1) stated that another licensed vocational nurse (LVN2) was discharging Resident 2 and Resident 1 on 8/28/2023, at the same time. LVN 1 stated that he offered to assist LVN 2, so he helped discharge Resident 2. LVN 1 stated that he gave Family 2 a file of discharge documents, which he later found out contained personal information of Resident 1. LVN 1 stated that he should have double checked the paperwork before handing it out to Family 2. LVN 1 stated that it was important to protect the privacy and personal information of all residents. LVN 1 stated that residents could be at risk for identity theft. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 2 of 3 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 10/25/2023 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and concurrent record review on 10/25/2023 at 1 pm of Resident 1's Order Summary Report dated 8/26/2023, the DON stated that the file of documents accidentally given to Resident 2's family (Family 2) that contained Resident 1's personal information, including full name, date of birth , diagnoses and medication orders (Order Summary Report). The DON stated that breach of privacy might result in using the other person's private information for the wrong reasons as well as the potential for the resident and/or family to feel uncomfortable. The DON stated that the paperwork should have been double checked by the LVNs prior to handing it out to both residents (Residents 1 and 2) on 8/28/2023. The DON stated that it was the facility's responsibility to protect the resident's private information. A review of the facility's undated policy titled, HIPAA Privacy and Security Operational Policy and Procedure, indicated that, HIPAA Privacy rule creates national standards to protect a resident's medical record and other personal health information. As healthcare providers we use and disclose sensitive individually identifiable information daily and it is our duty to protect that information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 3 of 3