Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
observation, interview, and record review, the facility failed to establish a system of surveillance designed to
prevent the spread of communicable diseases that included Coronavirus -19 (COVID 19 – a highly
contagious disease caused by a virus) for one of 24 sampled residents (Resident 1), who had a positive
test result and symptomatic for the COVID 19 virus. In addition, the facility failed to report the COVID 19
positive resident as a potential disease outbreak, to the local health officer and the California Department of
Public Health (CDPH).
Residents Affected - Some
This deficient practice had the potential for the virus to spread among residents, staff, and visitors which
can negatively affect the resident ' s health and quality of life.
Findings:
A review of Resident 1 ' s admission Record dated 2/2/2024, the indicated Resident 1 was admitted to the
facility on [DATE], with diagnoses including Corneal transplant (to remove all or part of a damaged cornea
and replace it with healthy cornea tissue from a donor), asthma (is a common long-term condition that can
cause coughing, wheezing, chest tightness and breathlessness) and diabetes (is a lifelong condition that
causes a person's blood glucose (sugar) level to become too high).
During a review of Resident 1 ' s Minimum Data Set (MDS) -a standardized assessment and screening tool
dated 12/26/23, the MDS indicated Resident 1 was cognitively intact. The MDS indicated Resident 1
required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or
contact guar assistance as resident completes activity) during eating, personal hygiene, toileting, sit to
lying, chair/bed to chair transfer, partial/moderate assistance (helper does less than half the effort) with
shower/bathing self.
A review of Resident 1 ' s Progress Notes dated 1/14/2024 timed at 9:15 AM, indicated Resident 1 had a
change in condition. The Progress Note indicated Resident 1 had a fever. The Progress Note indicated the
physician was notified.
A review of Resident 1 ' s Progress Notes dated 1/14/2024 timed at 10:22 AM, indicated Resident 1 was
immediately placed on transmission-based precautions (A method or technique of caring for patients who
have communicable diseases.) for suspected case of COVID 19 . Assessed possible exposures and closed
contact exposures . Explained to resident guidelines to COVID 19 and treatment to COVID 19, will be
Paxlovid for 5 days [sic] .
A review of Resident 1 ' s Rapid antigen test for COVID 19 dated 1/14/2024, indicated COVID 19 positive
result.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
555796
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
02/02/2024
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
A review of Resident 1 ' s Order Summary Report dated 1/14/2024, indicated Resident 1 was started on
Paxlovid (oral antiviral pill used to treat COVID-19 disease) (300/100) oral tablet therapy with NirmatrelvirRitonavir (treat mild to moderate COVID-19 disease) twice a day for 5 days for COVID 19 disease.
During an interview on 2/2/2024 at 3:30 PM with the Infection Preventionist Nurse (IP), the IP stated
Resident 1 was symptomatic with headache and a fever on 1/14/2024 and tested positive for COVID 19 and
was treated with Paxlovid. The IP stated, she did not report the facility ' s COVID 19 positive resident
(Resident 1) to the CDPH because she was told by staff that Resident 1 probably got the virus from his
visitors and medical appointments. The IP stated, she should have reported the COVID 19 positive result to
CDPH. The IP stated she reported Resident 1 ' s COVID 19 positive result to Redcap (online survey for
skilled nursing facilities [SNFs] to report COVID-19 information [local health officer]). The IP stated she
could not provide documented evidence or have a confirmation that the possible COVID 19 outbreak was
reported to Redcap. The IP stated she did not follow up and did not have any communication with the local
health officer or the LA County Public Health Nurse (PHN). The IP stated, she did not have any proof of
confirmation, that she reported it to Redcap [local health officer] or CDPH.
During an interview and record review on 2/2/2024 at 4:30 PM with the IP, in the presence of the
Administrator (ADM), the IP showed a printed picture of 24 Covid test kits with residents' names written on
each kit and 17 Covid test kits with names of staff written on each kit that was tested on Day 1 (1/15/2024)
of the facility's COVID 19 exposure. The IP stated, she used the picture of the test kits as her list of
residents and staff that were tested on Day 1. The IP stated she should have tested the residents exposed
on Day 3 and Day 5 of exposure as well, but did not. The IP stated, she did not have a surveillance tracking
log or surveillance tool to track residents and staff who had close exposure with Resident 1. The IP stated it
was important to have a surveillance tracking to heightened alertness to people who were exposed to
COVID 19 to prevent further spread of the virus.
During an interview on 2/2/2024 at 5 PM with the ADM, the ADM stated the facility should have notified the
CDPH and local health officer or Redcap when Resident 1 turned up positive for COVID 19 on 1/14/2024.
The ADM stated the IP should have developed a tracking and surveillance system for COVID-19 when
Resident 1 turned out positive for COVID 19 that included those residents/staff that was exposed to prevent
the spread of the virus.
A review of a LAC DPH document titled Coronavirus 2019 Guidelines for Preventing and Managing Covid
19 in Skilled Nursing Facilities, under reporting requirements, (undated), indicated; a) Skilled nursing facility
(SNF) are required to report within 24 hours any suspected COVID-19 outbreak to both Public Health (LAC
DPH) and Licensing and Certification, b) note: the current COVID -19 outbreak definition for SNFs in Los
Angeles County is at least one PCR/NAAT laboratory confirmed case of covid 19 (symptomatic or
asymptomatic) OR at least one symptomatic (sign) case with positive SARS-Cov-2 antigen result who has
been in the facility for at least 7 days.
A review of the facility ' s policy and procedure (P&P) titled, Infection Surveillance (Outcome) and Reporting
, revised 12/2023 , indicated; a) facility to maintain an ongoing system designed to identify possible
communicable diseases or infections to ensure that measures are taken to prevent any potential outbreaks,
b) Outbreaks and/or individual communicable diseases will be reported to local/state health departments or
other agencies, according to CDC guidelines. The P&P indicated; 1) infection control surveillance log is
maintained by IP, 2) IP/DNS/Designee will review the log during the morning routine to ensure all
potential/actual infections outbreaks are being identified, 3) should
(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
02/02/2024
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 0880
Level of Harm - Minimal harm
or potential for actual harm
any residents or staff be suspected or diagnosed as having a reportable communicable/infectious disease
according to state- specific criteria, such information shall be promptly reported to appropriate local and/or
state health department officials.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555796
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the February 2, 2024 survey of MISSION CARE CENTER?
This was a inspection survey of MISSION CARE CENTER on February 2, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MISSION CARE CENTER on February 2, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.