Health inspection·February 18, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some do not want the residents to feel embarrassed and we want them to feel comfortable especially if they are in their room. During a review of the facility ' s policy and procedure (P&P) titled, Dignity and Respect, revised 12/2023, P&P indicated, residents will be appropriately dressed in clean clothes arranged comfortably on their persons and be well groomed. The P&P indicated a closed door or drawn curtain shields the Resident from passers-by. 2.During a review of Resident 26 ' s admission Record, indicated the facility admitted Resident 26 on 1/22/2024 with diagnoses that included sepsis (life-threatening condition that arises when the body's response to infection injures its own tissues and organs), unidentified organism and psoas muscle (helps to bring the leg toward the torso [hip flexion] or vice versa) abscess (painful collection of pus). During a review of Resident 26 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/24/2024, the MDS indicated, Resident 26 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated, required total dependence with eating, oral hygiene, toileting hygiene, shower and personal hygiene. During an observation on 2/16/2024 at 7:42 pm with MDS Coordinator (MDSC) Resident 26 was observed awake lying in bed with bilateral post-operative surgical suction drain left uncovered without a dignity bag (privacy cover). During an interview on 2/18/2024 at 1:11 pm, with facility Director of Nursing (DON), the DON stated, JP drain bag should have a privacy bag to provide Resident 26 ' s with privacy, respect, and dignity. During a concurrent interview and record review of facility ' s policy titled Indwelling Urinary Catheter, revised 12/2023, with the DON, the P&P indicated to cover the drainage bag with a privacy bag to maintain dignity. The DON stated, the P&P applied to all body fluid collection device such as JP drain to be covered with dignity bag. 3.During a dining observation on 2/18/2024 at 12:31 pm, observed LVN 1 at the dining room sitting on a chair, drinking coffee while talking and supervising the residents during mealtime. During an interview on 2/18/2024 at 12:33 pm with LVN 1, LVN 1 stated he was not allowed to drink any beverage or eat while supervising the residents at the dining room. LVN 1 stated he should be watching the residents while eating. During an interview on 2/18/2024 at 12:38 pm, with the facility ' s DON, the DON stated, staff should not drink or eat while supervising the residents. The DON stated, staff could go to the breakroom for meal break. The DON stated, staff should focus watching residents during mealtime to respect residents' dignity. During a review of the facility ' s policy and procedure (P&P) titled, Dignity and Respect, revised 12/2023, P&P indicated, the staff shall display respect for Resident ' s when speaking with, caring for, or talking about them, as a constant affirmation for their individuality and dignity as human beings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 2 of 19 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 02/18/2024 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 provide reasonable accommodation of need for one of one sampled resident (Resident 157) who was at risk for fall, by failing to ensure the resident's call light was within reach as indicated in the facility's policy and procedure and resident's care plan. Residents Affected - Few This deficient practice had the potential for Resident 157 not to receive or received delayed care to meet necessary care and services that could result in fall and accident. Findings: A review of Resident 157 ' s admission Record indicated an admission on [DATE] with diagnoses of multiple fractures (partial or complete break in the bone) of ribs (right side), disorientation (altered mental state), and Parkinson ' s Disease (age-related degenerative brain condition, causes parts of the brain to deteriorate) without dyskinesia (involuntary, erratic, writing movements of the face, arms, legs or trunk). A review of Resident 157 ' s History and Physical assessment dated [DATE], indicated Resident 157 did not have decision-making capacities. A review of Resident 157 ' s Care plan dated 2/4/2024 indicated Resident 157 was at risk for falls related to decrease bed mobility, status post fall with posterior right rib fracture. The care plan indicated to be sure the call light was within reach and encourage to use it to call for assistance as needed. A review of Resident 157 ' s Fall Risk Evaluation dated 2/3/2024 indicated Resident 157 was high risk for falls. During a concurrent observation and interview in Resident 157 ' s room on 2/16/2024 at 8:22 PM, Resident 157 ' s call light was observed by resident ' s feet near the end of his bed. Resident 157 stated he was unable to reach call light. During a concurrent observation and interview in Resident 157 ' s room on 2/16/2024 at 8:25 PM, the Minimum Data Set (MDS) Nurse confirmed the placement of the call light was on top of Resident 157 ' s feet. MDS Nurse stated Resident 157 is at risk for falls and the call light should be closer to the resident. During an interview with the Director of Nursing (DON) on 2/18/2024 at 6:48 PM, the DON stated it is important for resident ' s call light to be within reach so that the resident can call when help is needed and to prevent a fall. A review of the facility ' s policy and procedure titled Call Light, dated 12/2023 indicated to leave the resident comfortable and to place the call device within resident ' s reach before leaving room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 3 of 19 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 02/18/2024 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 0623 Level of Harm - Minimal harm or potential for actual harm Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to follow the facility's policy on Notice Requirements Before Transfer or Discharge for one (1) of three (3) sampled residents (Resident 53), by failing to: Residents Affected - Few 1. Ensure the Notice of Proposed Transfer and Discharge was provided to the resident's responsible party. 2. Provide documentation to show that the State Long Term Care Ombudsman (public advocate) was notified of Resident 53 ' s transfer to the General Acute Hospital (GACH) on 11/26/2024. This deficient practice had the potential for Resident 53's rights to ensure for an appropriate discharge/transfer from the facility. Findings: A review of Resident 53 ' s admission Record indicated the facility admitted Resident 53 on 11/17/2023, with diagnoses that included disorders of the brain. During a review of Resident 53's Order Summary Report (Physicians Order) dated 11/26/2024, indicated to transfer Resident 53 to the GACH emergency room (ER) due to altered mental status, increased sleepiness. During a concurrent interview and record review of Resident 53 ' s Notice of Proposed Transfer/Discharge Form on 2/18/2024 at 12:08 PM, with the facility ' s Director of Nursing (DON), the DON stated Resident 53 ' s Notice of Proposed Transfer/Discharge Form was not completed. The DON stated the notice was not signed by Resident 53 ' s representative and a copy of the notice was not sent to the Ombudsman. The DON stated the purpose of the notice was to know where the resident will be transferred. During a concurrent interview and record review of Resident 53 ' s Notice of Proposed Transfer/Discharge Form on 2/18/2024 at 2:25 PM, with the facility ' s Assistant Director of Medical Records (ADMR), the ADMR stated the notice was not signed by Resident 53 ' s representative and a copy was not sent to the Ombudsman. During a concurrent interview and record review of Resident 53 ' s Notice of Proposed Transfer/Discharge Form on 2/18/2024 at 2:32 PM, with the facility ' s Director of Medical Records (DMR), the DMR stated the notice was not signed by Resident 53 ' s representative and a copy was not sent to the Ombudsman. The DMR stated, the resident ' s representative needed to sign the notice and should be faxed to the Ombudsman ' s office and attached the copy of the fax transmittal form in resident's chart. The DMR stated there was no other clinical documentation that indicated the Ombudsman was notified Resident 53 ' s planned transfer. A review of the facility's Policy and Procedure (P&P) titled Notice Requirements Before Transfer or Discharge, revised 3/2023, indicated for any types of facility - initiated discharges, the facility must provide notice of discharge to the resident and resident representative, along with a copy of the notice to the office of the State Long Term Care Ombudsman at least 30 days prior to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 4 of 19 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 02/18/2024 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 0623 Level of Harm - Minimal harm or potential for actual harm discharge or as soon as possible. The P&P indicated, the copy of the notice to the ombudsman must be sent the same time notice is provided to the resident and resident representative, when the discharge is initiated by the facility. The P&P indicated when a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility - initiated transfer and a notice of transfer must be provided to the resident and resident representative as soon as practicable. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 5 of 19 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 02/18/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement individualized person-centered plans of care with measurable objectives, timeframes, and interventions to meet the residents ' needs for six (6) of 6 sampled residents (Residents 1, 16, 27, 26, 31, and 30). 1. For Resident 26, the facility failed to develop a care plan to indicate interventions to manage Resident 26 ' s peripheral intravenous catheter (IV, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids and/or blood products). 2. For Resident 27, the facility failed to develop an individualized, person- centered care plan to indicate interventions to manage Resident 27's diagnosis of atrial fibrillation (when the atria or the upper chambers of the heart contract at an excessively high rate and in an irregular way) while receiving Xarelto (blood thinner - a medication that thins the blood and could cause bruising or bleeding) medication. 3. For Resident 31, develop a care plan that included to monitor for the use of Aspirin (acetylsalicylic acid (ASA), a medication used to treat pain, reduce fever of if inflammation, prevent heart attacks, strokes, and chest pain). 4. Resident 16, the facility failed to develop a care plan to monitor and assess Resident ' s 16 ' s IV site. 5. For Resident 30, the facility failed to develop a care plan for continuous oxygen via nasal cannula. 6. For Resident 1, the facility failed to develop a care plan for the use of Eliquis (anticoagulant medication used to treat and prevent blood clots) as ordered by the physician. These deficient practices had the potential for the residents to not receive appropriate care treatment and/or services. Findings: 1. A review of Resident 26's admission Record indicated the facility admitted Resident 26 on 1/22/2024, with diagnoses that included sepsis (life-threatening condition that arises when the body's response to infection injures its own tissues and organs), unidentified organism and psoas muscle (helps to bring the leg toward the torso [hip flexion] or vice versa) abscess (painful collection of pus). A review of Resident 26's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/24/2024, indicated, Resident 26 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 26 was totally dependent on staff with eating, oral hygiene, toileting hygiene, shower and personal hygiene. During a review of Resident 26's Physicians Order, dated 1/29/2024, the Physician's Order indicated to start (IV) intravenous and change the IV site every 72 hours and as needed for infiltration (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 6 of 19 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 02/18/2024 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 0656 (when fluid leaks out of the vein into surrounding soft tissue) or soiling. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 2/18/2024 at 9:06 AM, with the facility's Assistant Director of Nursing (ADON), Resident 26's, the ADON stated there was no other clinical documentations that a care plan was developed for Resident 26's IV site. The ADON stated care plan should have been developed to ensure Resident 26 received proper care from the nursing staff. Residents Affected - Some 2. A review of Resident 27's admission Record indicated the facility admitted Resident 27 on 1/5/2024, with diagnoses that included unspecified atrial fibrillation. A review of Resident 27's MDS dated [DATE] indicated, Resident 27's cognition for daily decision making was severely impaired. The MDS indicated Resident 27 required moderate assistance with upper/lower body dressing, and personal hygiene. During review of Resident 27's Physician Orders, dated 1/5/2024 indicated to administer Xarelto (Rivaroxaban) one tablet 10 milligrams (mg, unit of measurement) by mouth daily in the evening with food for atrial fibrillation. During a concurrent interview and record review of Resident 27's active care plans, on 2/18/2024 at 8:50 AM, with the facility's MDS Coordinator (MDSC), the MDSC stated there was no other clinical documentations that a care plan was developed for Resident 27 who had a diagnosis of atrial fibrillation and on Xarelto use. The MDS Nurse stated care plan should have been initiated to ensure Resident 27 to received proper nursing interventions and care from the nursing staff. MDSC stated that a care plan should have been initiated within 72 hours upon resident's admission. During a concurrent interview and record review of Resident 27's 2 care plans, on 2/18/2024 at 11:59 AM, with the facility's Director of Nursing (DON), the DON stated care plan should have been initiated for Resident 27, to provide guidance to staff on how to treat the residents. 3. A review of Resident 31's admission Record indicated a readmission on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (stoke, damage to tissues in the brain due to loss of oxygen to the area) affecting left non-dominant side, malignant neoplasm (cancerous tumor, abnormal growth of tissue) of prostate, and vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage). A review of Resident 31's latest comprehensive Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/27/2024, indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of Resident 31's Physician Order Summary indicated on 9/4/2023, the physician prescribed Aspirin 81 milligrams (mg, unit of measure for mass) give 1 tablet by mouth one time a day for coronary artery disease (CAD, disease caused by plaque buildup in the wall of the arteries that supply blood to the heart) with food. The physician also ordered on 9/5/2023, to monitor for signs and symptoms of bleeding, bruises, nosebleed, ulceration and perforation of the stomach or intestines (ASPIRIN) every shift. During a concurrent interview and record review of Resident 31's care plans on 2/18/2024 at 10:49 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 7 of 19 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 02/18/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some AM, Registered Nurse Supervisor (RNS) 1 stated there was no documented evidence of a care plan for the use of Aspirin. RNS 1 stated there should be a care plan to monitor for signs and symptoms like bleeding, to know when to notify the physician and to provide pertinent care to patient's use of Aspirin. 4. A review of Resident 16 ' s admission Record indicated Resident 16 was admitted to the facility on [DATE], with diagnoses that included cardiomyopathy (disease of heart muscle, this condition makes it hard for the heart to deliver blood to the body), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) A review of Resident 16 ' s MDS dated [DATE], indicated Resident 16 ' s was cognitively intact. The MDS indicated Resident 16 required setup or clean up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) eating, oral and personal hygiene. A review of Resident 16's Order Recap Report, dated 2/01/2024 to 2/29/2024 Included an order for Sodium Chloride solution 0.9% use 75 milliliters per hour intravenously every shift for intravenous hydration for two days. During an interview and observation on 2/16/2024 at 8:10 PM with Resident 16, Resident 16 stated she was receiving Intravenous fluid hydration at the facility. Resident 16 stated she had her intravenous catheter inserted by one of the nurses at the facility a day before. During an interview and concurrent record review of Resident 16 ' s medical record, on 2/18/2024 at 10:40 AM, with the Assistant Director of Nursing (ADON), the ADON stated there was no care plan for Resident 16 ' s intravenous catheter. The ADON stated a care plan should have been developed with interventions and monitoring for the intravenous catheter that was ordered to be placed for Resident 16. 5. A review of Resident 30 ' s admission Record indicated Resident 30 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs(COPD)), acute respiratory failure with hypoxia (a condition where you don ' t have enough oxygen in your body tissues). A review of Resident 30 ' s History and Physical dated 1/30/2024, indicated Resident 30 had the capacity to understand and make decisions. A review of Resident 30 ' s MDS dated [DATE], the MDS indicated Resident 30 required substantial/maximal assistance (helper does more than half the effort) for eating, oral and personal hygiene. The MDS indicated Resident 30 was dependent (helper does all of the effort) for toileting, shower/bath and upper and lower body dressing. The MDS indicated Resident 30 was on continues oxygen therapy. A review of Resident 30's Order Summary Report dated 2/01/2024 to 2/29/2024 Included an order for continuous oxygen at 2 liters per min via nasal cannula/mask to keep oxygen saturation above 90% every shift for COPD. During an interview and concurrent record review on 2/18/2024 at 5:24 PM, with the Director of Nursing (DON) of Resident 30 ' s medical record, the DON stated there was no care plan for Resident 30 ' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 8 of 19 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 02/18/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some s use of continuous oxygen. The DON stated a care plan should have been initiated when the order for the continuous oxygen was made. The DON stated it was important to have a care plan for the use of continuous oxygen with interventions and goals to help make sure the resident is receiving the best care and prevent complications. 6. A review of Resident 1 ' s admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses that included osteomyelitis(Inflammation of bone caused by infection) of vertebra(small bones forming the backbone), sacral and sacrococcygeal region (the tailbone) and paraplegia(a type of paralysis that affects your ability to move the lower half of your body). A review of Resident 1 ' s MDS dated [DATE], the MDS indicated Resident 1 was cognitively intact. The MDS indicated Resident 1 required set up or clean up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating and oral hygiene. The MDS indicated Resident 1 required was dependent (helper does all of the effort) for toileting, lower body dressing and putting on/ taking off footwear. A review of Resident 1's Order Summary Report dated 2/18/2024 Included an order for Eliquis oral tablet 5mg (Apixaban) give 1 tablet by mouth two times a day for Chronic left femoral deep vein thrombosis, with a start date of 12/02/2023. During an interview and concurrent record review of Resident 1 ' s medical record, on 2/18/2024 at 11 AM, with the ADON, the ADON stated there was no care plan for Resident 1 ' s use of Eliquis. The ADON stated it was important to have a specific care plan for the use of Eliquis with specific goals and interventions for the nurses to be able and monitor and prevent complications associated with this specific medication. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person - Centered Care Planning, revised 12/2023, the policy indicated the facility Interdisciplinary Team (IDT) will develop and implement a comprehensive person-centered, culturally-competent and trauma-informed care plan for each resident within 7 days of completion of the resident MDS and will include residents needs identified in the comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 9 of 19 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 02/18/2024 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 ensure two of three sampled residents (Resident 16 and 26) follow the facility ' s policy and procedure on Intravenous Therapy by failing to: Residents Affected - Some 1. Label and date intravenous catheter (IV, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids and/or blood products) for Resident 26. 2. Obtain a physician order for IV catheter insertion for Resident 16. These deficient practices had the potential to put the residents at risk for intravenous complications without appropriate intervention or preventive measures. Findings: 1. A review of Resident 26 ' s admission Record, indicated the facility admitted Resident 26 on 1/22/2024, with diagnoses that included sepsis (life-threatening condition that arises when the body's response to infection injures its own tissues and organs), unidentified organism and psoas muscle (helps to bring the leg toward the torso [hip flexion] or vice versa) abscess (painful collection of pus). During a review of Resident 26 ' s MDS dated [DATE], the MDS indicated, Resident 26 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated, Resident 26 required total dependence with eating, oral hygiene, toileting hygiene, shower and personal hygiene. During a review of Resident 26's Physician ' s Order, dated 1/29/2024, indicated to start intravenous and change site every 72 hours and as needed for infiltration (when fluid leaks out of the vein into surrounding soft tissue) or soiling. During a concurrent observation and interview on 2/16/2024 at 7:46 PM, with the MDS Coordinator (MDSC), Resident 26 was awake lying in bed with an IV site that was not dated to when it was inserted. The MDSC stated Resident 26 ' s peripheral IV line should be labeled with the date when it was inserted and the initial of the licensed nurse who inserted the IV line. During an interview with facility Director of Nursing (DON) on 2/18/2024 at 12:17 PM, the DON stated IV sites should be labeled with date and with licensed nurse ' s initial to identify when it was inserted for infection control. 2. A review of Resident 16 ' s admission Aecord indicated Resident 16 was admitted to the facility on [DATE], with diagnoses that included cardiomyopathy (disease of heart muscle, this condition makes it hard for the heart to deliver blood to the body), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 16 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/20/2023, the MDS indicated, Resident 16 ' s was cognately (thinking, reasoning, or remembering) intact. The MDS indicated Resident 16 required setup or clean up assistance (helper sets up or cleans up; resident completes activity. The MDS indicated the helper assist only prior to or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 10 of 19 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 02/18/2024 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 0694 following the activity) eating, oral and personal hygiene. Level of Harm - Minimal harm or potential for actual harm A review of Resident 16's Order Recap Report, dated 2/01/2024 to 2/29/2024, did not indicate a physician order for intravenous catheter. Residents Affected - Some A review of Resident 16's Order Recap Report, dated 2/01/2024 to 2/29/2024, included an order for Sodium Chloride solution 0.9% use 75 milliliters per hour intravenously every shift for intravenous hydration for 2 days. During an interview and observation on 2/16/2024 at 8:10 PM, with Resident 16, Resident 16 stated she was receiving intravenous fluid hydration at the facility. Resident 16 stated she had her intravenous catheter inserted by one of the nurses at the facility a day before. During an interview and concurrent record review on 2/18/2024 at 10:34 AM, with the Assistant Director of Nursing (ADON), the ADON stated there was no physician order found for Resident 16 ' s intravenous catheter insertions. The ADON stated there was no clinical documentation on Resident 16 ' s medical record when was the intravenous catheter was inserted. The ADON stated all nurses should obtain an order from the physician prior to inserting an intravenous catheter. The ADON stated licensed nurses should document in the resident ' s record assessment and the site of the intravenous catheter. During a review of the facility ' s undated policies and procedure (P&P) titled, Intravenous Therapy, indicated, all dressing changes will be labeled (time, date, and initials) and documented in medical record on IV medication record. A review of the facility ' s policy and procedure titled Guidelines for administering intravenous therapy (not dated), indicated The licensed nurse will check physicians order for the completeness . Complete orders include: 7. site rotation . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 11 of 19 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 02/18/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 promote resident safety in administering oxygen for four (4) of 4 sampled residents (Residents 40, 154, 205, and 30) who were receiving oxygen therapy, in accordance with the facility ' s policy and procedure: Residents Affected - Some 1. For Resident 40, that facility failed to ensure the resident ' s nasal cannula tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was not touching the floor when in use. 2. For Resident 154, the facility failed to ensure the Yankaeur suction tip (an oral suctioning tool) was not on the floor and post Oxygen/no smoking signage for Resident 154. 3. For Resident 30, the facility failed to have the resident ' s room post a signage indicating Oxygen in use and No Smoking Sign, as per facility policy. 4. For Resident 205, the facility failed to ensure the resident ' s oxygen equipment was labeled or dated, a storage bag should be at bedside, and to post a signage indicating Oxygen in use, and No Smoking Sign, as per facility policy. These deficient practices had the potential for the residents to contract infection while receiving oxygen therapy which could increase the risk of the spread of infection to the residents, staff, and other visitors in the facility. Findings: 1. A review of Resident 40 ' s admission Record indicated the facility admitted Resident 40 on 11/24/2023, with diagnoses that included atherosclerotic heart disease (general term for the progressive narrowing and hardening of coronary arteries due to atheroma [degeneration of the walls of the arteries caused by accumulated fatty deposits and scar tissue, and leading to restriction of the circulation] deposition) of native coronary artery disease without angina pectoris (chest pain or discomfort). A review of Resident 40 ' s MDS dated [DATE], indicated Resident 40 had moderately impaired cognition for daily decision making. The MDS indicated, Resident 40 required maximum assistance with oral hygiene, toileting hygiene, upper/lower body dressing and personal hygiene. A review of Resident 40's Order Summary Report, dated 2/16/2024, indicated to administer continuous oxygen at two (2) liters per minute (L/min) via nasal cannula/mask, to keep oxygen saturation (is a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) above 90% every shift. A review of Resident 40's Order Summary Report, dated 2/16/2024, indicated to change oxygen tubing and humidifier humidifiers (a device used to make supplemental oxygen moist), masks and cannulas used to deliver oxygen will be changed weekly) every Monday at night shift. During an observation on 2/16/2024, at 7:37 PM, in the presence of Registered Nurse (RN) 1, Resident 40 was awake, lying in bed with oxygen tubing touching the floor. RN 1 stated oxygen tubing should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 12 of 19 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 02/18/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some be off the floor because the floor is dirty and can cause cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During an interview on 2/18/2024 at 12:01 PM with the facility ' s Director of Nurses (DON), the DON stated oxygen tubing should not be touching the floor. The DON stated, oxygen tubing should be off the floor because the floor is dirty and to prevent infection. 2. A review of Resident 154 ' s admission Record indicated an admission to the facility on 2/9/2024 with diagnoses of chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), pneumonitis (lung inflammation that can cause difficulty breathing and is often accompanied by a cough) due to inhalation of food and vomit, unspecified systolic congestive heart failure (the left ventricle loses its ability to contract normally, when the heart does not pump blood effectively). A review of Resident 154 ' s History and Physical assessment dated [DATE], indicated Resident 154 had limited decision-making capacities. A review of Resident 154 ' s Order Summary Report indicated the following physician orders: On 2/9/2024, Continuous Oxygen at 3 liters (L, unit of measure) per minute via nasal cannula/mask (medical device to provide supplemental oxygen therapy) to keep oxygen saturation (the amount of oxygen that is circulating in the blood) above 90% every shift On 2/11/2024, may suction orally as needed for excessive secretion every 4 hours During a concurrent observation and interview in Resident 154 ' s room on 2/16/2024 at 8:16 PM, Resident 154 was observed sitting on his bed and receiving oxygen therapy via nasal cannula. Resident 154 ' s yankaeur suction was observed on the floor next to the resident ' s bed. Resident 154 stated he uses the yankaeur suction often and did not know when it fell to the floor. During a concurrent observation and interview in Resident 154 ' s room on 2/16/2024 at 8:19 PM, Licensed Vocational Nurse (LVN) 1 confirmed Resident 154 ' s yankaeur suction was on the floor next to the resident ' s bed. LVN 1 stated the suction should not be on the floor because of infection control, it was dirty. LVN 1 stated the yankaeur suction will not be reused and he will provide a new suction for Resident 154. During a concurrent observation and interview outside of Resident 154 ' s room on 2/16/2024 at 8:31 PM, there was no signage to indicate Oxygen/ No smoking found prior to entering Resident 154 ' s room. LVN 2 confirmed there was no signage to indicate oxygen use. LVN 2 stated there should be signage at resident ' s door entrance to inform whoever was coming in that Resident 154 is on oxygen therapy use and there should be no smoking. During an interview with the Director of Nursing (DON) on 2/18/2024 at 6:48 PM, the DON stated it is important for respiratory equipment like the Yankaeur suction to be kept off the floor for infection control, to avoid spreading infection. 3. A review of Resident 30 ' s admission Record indicated Resident 30 was initially admitted to the facility on [DATE], and then readmitted on [DATE] with diagnoses that included chronic obstructive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 13 of 19 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 02/18/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs(COPD)), acute respiratory failure with hypoxia (a condition where you don ' t have enough oxygen in your body tissues). A review of Resident 30 ' s History and Physical dated 1/30/2024 indicated Resident 30 had the capacity to understand and make decisions. A review of Resident 30 ' s MDS dated [DATE], the MDS indicated Resident 30 required substantial/maximal assistance (helper does more than half the effort) for eating, oral and personal hygiene. The MDS indicated Resident 30 was dependent (helper does all of the effort) for toileting, shower/bath and upper and lower body dressing. The MDS indicated Resident 30 was on continues oxygen therapy. A review of Resident 30's Order Summary Report dated 2/01/2024 to 2/29/2024 included an order for continuous oxygen at 2 liters per min via nasal cannula/mask to keep oxygen saturation above 90% every shift for COPD. During an concurrent interview and observation of Resident 30 ' s room on 2/16/2024 at 8:22 PM, with Infection Prevention Nurse (IPN), Resident 30 was observed with nasal canula (NC-flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient ' s ears) tubbing around ears and continuous oxygen on at 2 liters, no signage was observed inside or outside Resident 30 ' s room to indicate oxygen in use. The IPN stated Resident 30 ' s room should have signage per facility policy to indicate oxygen was in use and no smoking should occur to make everyone aware and be cautions before entering Resident 30 ' s room. 4. A review of Resident 205 ' s admission Record indicated Resident 205 was admitted to the facility on [DATE], with diagnoses that included Diverticulosis (a condition in which small, bulging pouches develop in the digestive tract) of large intestine without perforation without bleeding, muscle weakness. A review of Resident 205 ' s History and Physical dated 2/15/2024, indicated Resident 205 had the capacity to understand and make decisions. A review of Resident 205's Order Summary Report dated 2/18/2024, included an order for continuous oxygen at 3 liters per min via nasal cannula (NC-flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient ' s ears) to keep oxygen saturation above 90% every shift. During a concurrent interview and observation of Resident 205 ' s room on 2/16/2024 at 8:40 PM with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 205 ' s oxygen tubing was not labeled or date and there was no storage bag and there was no signage inside or outside Resident 205 ' s room to indicate oxygen in use, no smoking per facility policy. LVN 1 stated it was important to date and label oxygen equipment to know when it was placed and when to change to prevent infections. A review of the facility ' s policy and procedure titled Oxygen Administration (Mask, Cannula, Cathether (tube)) dated 12/2023 indicated oxygen therapy equipment included no smoking/oxygen signs. A review of the facility ' s policy and procedure titled Disposition of Respiratory equipment Disposables, dated 12/2023 indicated the disposable change out schedule for Yankaeur suction tip was weekly and as needed. The policy indicated as needed, as determined by clinical team due to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 14 of 19 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 02/18/2024 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 0695 malfunctioning or broken, or unusually soiled. The policy further indicated that disposables on oxygen tubing to change weekly and as needed. 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: 555796 If continuation sheet Page 15 of 19 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 02/18/2024 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow proper sanitation and safe food handling based on the facilities policy and procedure by failing to ensure: 1.Kitchen staff wear hair covering while in the kitchen to prevent hair from falling on food surface areas that can lead to contamination 2.Label used or opened food items with an open or use by date in the kitchen refrigerator, kitchen freezer, food preparation area and dry goods storage area to indicate when foods are no longer safe to eat. These deficient practices had the potential to put residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: During the initial observation of the kitchen on 2/18/2024 at 6:50 PM, Kitchen assistant 1(KA 1) was observed entering the kitchen, not wearing a hair net then proceed to go into kitchen refrigerator and dry storage area with no hair net. During an observation in the kitchen on 2/18/2024 at 7:11 PM with KA of the food preparation area the following were observed: 1.Red powder in Ziplock bag with had a label with open date 2. Opened container of thickener had date opened 3. Opened [NAME] instant tea mix had open date 4. opened strawberry gelatin mix no open date During an observation and concurrent interview in the kitchen on 2/18/2024 at 7:17 PM with KA of the dry food storage area there was an observation of opened bag of toasted oats cereal ½ full without an open date. KA stated opened bag of toasted oat cereal did not have an open date and should have one to indicate when foods are no longer safe to eat. During an observation on 2/18/2024 at 6:57 PM in the facility ' s freezer with KA, there was an observation of: 1. A large bag of ice was observed on the freezer floor 2. An opened box of popsicles with no open date, covering the vent in freezer. 3. An opened box of breaded half-moon mozzarella with no open date During an observation on 2/18/2024 at 7:22 PM of the kitchen refrigerator with KA, a clear plastic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 16 of 19 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 02/18/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bin containing a clear bag of thawed chicken pieces with red liquid at the bottom was observed with no label or date. KA stated he will throw out thawed chicken immediately as it had no date of when it was thawed out. During a concurrent interview with KA at 7:30, KA stated hair nets should be worn in the kitchen all the time but forgot to put one on as he was returning from the bathroom. KA stated all opened and used food should have an open date or use by date. During a follow up interview with Dietary supervisor on 2/19/2024 at 8:52 AM, DS stated all opened food items should be labeled with a date opened to ensure the quality of the food. DS stated any food that was thawed out should be dated to prevent food contamination. DS stated all staff in the kitchen should always wear a hair net covering the hair to prevent cross contamination of Residents food items. A review of facility policy titled Freezer Storage dated 2003, indicated 6. All frozen food should be labeled and dated 8. Frozen food should be left in the refrigerator to thaw. Once thawed, uncooked meats are to be used within 2 days. 10. All food and non-food containers are to be stored 6 of the floor and 18 from sprinkler heads, if applicable. Food items should be stored on clean surfaces in a manner that protects it from contamination. A review of facility policy titled Labeling and dating of foods dated 2023, indicated: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for either food safety or product rotation. A review of facility policy titled Dress code dated 2023 indicated Appropriate dress in the food & Nutrition services department . 6. Hat for hair, if hair is short, which completely covers the hair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 17 of 19 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 02/18/2024 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 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 maintain a safe, sanitary environment to help prevent the spread of transmission of infections to residents, staff members, visitors in accordance with the facility ' s policy and procedure on infection control by failing to: Residents Affected - Some Ensure an open plastic container of sliced fruits for staff was not at the nursing station. Ensure Community Liaison (CL) wore personal protective equipment (PPE) that included an isolation gown (gown used to protect clothing from contaminants or contacting disease causing organism) and gloves while in the room of Resident 18, who was under contact isolation (containing one in an area prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or resident ' s environment) precautions. These deficient practices had the potential to increase the risk of the spread of infection to the residents, staff, and other visitors in the facility. Findings: During an observation of nursing station 1 on 2/16/2024 at 6:42 PM, Certified Nursing Assistant (CNA) 1 was observed putting fruits in a cup from an open plastic container with sliced fruits at nursing station. During an interview with CNA 1 and Registered Nurse (RN) 1 on 2/16/2024 at 6:44 PM, CNA 1 stated staff are not supposed to bring food or eat at the nursing station to prevent the spread of infection. RN 1 stated staff should not eat the nursing station because of infection control. RN 1 stated food should be kept and eaten in the break room. A review of Resident 18 ' s admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included nontraumatic subdural hemorrhage (medical condition where blood collects beneath the dura mater (the outermost membrane surrounding the brain)), dysphagia (swallowing difficulties), and unspecified dementia (a group of symptoms affecting memory, thinking, and social abilities). A review of Resident 18 ' s latest comprehensive Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 1/26/2024 indicated Resident 18 had severely impaired cognition. A review of Resident ' s 18 ' s Order Summary Report indicated a physician order dated 2/14/2024 for Transmission-Based Precaution: Contact- Clostridium Difficile (C. DIFF) every shift until 2/24/2024. During an observation on 2/17/2024 at 3:40 PM, a contact isolation signage was observed prior to entering Resident 18 ' s room. The signage indicated proper use of PPE that included to put on gloves and a gown before room entry. Observed another signage indicating Stop, please see the nurse before entering the room. CL was observed in Resident 18 ' s room not wearing and isolation gown or gloves. During an interview with CL on 2/17/2024 at 3:43 PM, CL stated she did not realize the room was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 18 of 19 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 02/18/2024 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 contact isolation until she saw the visitor inside Resident 18 ' s room was wearing a gown. CL stated she did not see the signage and was not aware that Resident 18 was on contact isolation. CL stated it is important to wear the correct PPE so that the contamination doesn ' t spread, to protect herself, the patient, and whoever goes into the room. During an interview with the infection prevention nurse (IPN) on 2/17/2024 at 4:08 PM, IPN stated C. DIFF is highly transmissible and staff should wear the proper PPE when in a contact isolation room to prevent infection. A review of the facility ' s policy and procedure titled Infection Prevention and Control Program Standard and Transmission-Based Precautions, dated 12/2023 indicated PPE for Contact Precautions require wearing a gown and gloves for all interactions that may involve contact with the patient or the patient ' s environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 19 of 19