Health inspection·January 24, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some them with an antigen test (a diagnostic test that detects the presence of Covid-19) to check if they are infected or recently tested positive of Covid-19 virus. 2. During an interview with the facility ' s infection preventionist (IP) on 1/24/2025 at 1:17 PM, the IP stated that a public health nurse (PHN) and an LA County physician conducted a virtual tour of the facility on 1/14/2025 and provided the facility with instructions on how to mitigate (control) the spread of Covid-19 that included a PCR testing of the staff and residents twice weekly. During an interview with the ADM on 1/24/2025 at 2:15 PM, the ADM stated that for the facility to initiate the PCR testing, the laboratory required a signature from the facility ' s medical director (MD) to execute the procedure. However, the ADM stated that the MD was on vacation and could not reached. The ADM stated that she tried to reach out to the MD on 1/22/2025, but to no avail. During a facility tour with the IP on 1/24/2025 at 2:30 PM, the breakrooms used by the staff who provided care to non-infected and infected residents was observed without hand sanitizers, facemasks, wipes, or a signage reminding the staff to change their masks after eating. There were five (5) chairs in one of the breakrooms and six (6) chairs in the other, with two staff observed working on their laptops next to each other in the breakroom for the staff providing care to infected residents. The breakroom was also observed with all windows and doors closed without an air purifier in the room. During a concurrent interview with LVN 2, who was in the breakroom, LVN 2 stated that he and the MDS nurse (minimum data set nurse) were working in the breakroom because they had a meeting with another group of staffs earlier. LVN 2 stated that he was not aware that there should only be two (2) people inside the room at any given time and should be across each other at the table. 3. During an observation on 1/24/2025 at 2:30 PM, three (3) residents, one (1) visitor, and four (4) staff members were observed occupying the Rehabilitation Room. A signage was posted in the room indicating that the room capacity was limited to three (3) people. The three residents and the visitor who were inside the room were not wearing facemasks and were not at least six feet apart from each other. 4. During an observation on 1/24/2025 at 2:45 PM, the kitchen was observed without a PPE cart and supplies available for use by the staffs. During an interview on 1/24/2025 at 2:55 PM, the ADM stated that the facility was having difficulty acquiring air purifiers and air filters due to a supply shortage caused by the recent fires. During an interview on 1/24/2025 at 3:55 PM, the IP stated that she thought three (3) residents were allowed in the rehabilitation room. The IP stated that there were five (5) chairs in the break room because the staff brought in the chairs from the patio despite giving them instructions not to bring more than two (2) chairs in the room. The IP stated that she failed to ensure that a signage was in place in each breakroom to remind the staff to change their masks after eating. The IP stated that she thought washing hands with soap and water was a better alternative to using hand sanitizers. The IP stated that she thought placing the facemasks at the nurses ' station was more effective than having them available in the breakrooms. The IP stated that the facility had difficulty acquiring air purifiers since the wildfires started due to a shortage of supply. The IP stated that she does not know why the windows were not cracked open in the breakrooms and does not recall receiving instructions from the PHN to leave them slightly open. (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 01/24/2025 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 an email sent to the IP by the PHN on 1/14/2025 at 10:27 AM, indicated that the PHN's post-site visit recommendations include: 1. Arrange for a lab to conduct PCR testing and begin PCR testing twice a week. 2. Create a testing station in the room adjacent to the front entrance where visitors and staff can sign in, conduct symptom checks, and test for Covid using an antigen test. 3. Allow only 1-2 masked residents and distanced residents in the rehabilitation room at a time. 4. Remove extra chairs and limit occupancy to two (2) people, seated across from each other. 5. Add signage reminding staff to change their masks after eating. 6. Provide masks, hand sanitizers, and wipes in the breakrooms. 7. Add an air purifier to the breakroom and keep windows cracked open. A review of a facility ' s Covid-19 Update Report, dated 1/23/25, indicated that the total number of confirmed Covid-19 cases in the facility was thirty-one (31), with five (5) staff and twenty-six (26) residents. The report indicated that the staff and residents were tested with an antigen test. A review of the facility ' s undated policy titled, Infection Prevention and Control Program, revised in 12/2023, indicated that the program would be carried out by the facility ' s infection preventionist with a goal to decrease the risk of infection to residents and personnel and to ensure compliance with the state and federal regulations related to infection control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555796 If continuation sheet Page 3 of 3