Inspection·September 17, 2024

F 0602 Level of Harm - Actual harm Residents Affected - Few involve feelings of distress, sadness, depression, or anxiety), Cognitive Communication Deficit (communication issues), Bipolar Disorder (a mental illness that causes extreme shifts in mood, energy, and activity levels). During an interview on 9/17/24, at 11:08 a.m. with Business Office Manager (BOM), BOM stated, Resident ' s [1] BIMS is a 6, in my personal opinion, she [Resident 1] does not have [mental] capacity. BOM stated the facility do not have a policy on financial protection for vulnerable residents having no capacity to manage their finances. 2. During an interview on 9/12/24 at 9:53 a.m. with Complainant, Complainant stated he is from the fraud (wrongful or criminal deception intended to result in financial gain) department at a bank. Complainant stated, A woman named [SSD] that works at [the facility] has been calling in and impersonating [pretending to be] [Resident 1] to gain access to her [Resident 1 ' s] accounts. Complainant stated, Reviewing all recorded phone calls in the past, [SSD] has called in with [Resident 1] present and has identified herself as the Social Services, a facility representative, however now, she is not, she is changing her voice and calling in stating her name is [Resident 1 ' s name]. Complainant stated, We locked resident ' s [1] debit card, however her credit card was not locked and has concerning charges such as from gas stations, shoe store with $200 charges, clothing store with $300 charges. There are several gas station charges. During an interview on 9/17/24 at 11:18 a.m. with SSD, SSD stated she did call the bank and stated her (SSD) name was Resident 1 ' s name because she (SSD) was trying to help her (Resident 1) get access to her (Resident 1) pin number because Resident 1 was asking for assistance to get a new pin number. SSD stated, [Resident 1] goes out shopping on the weekends with friends. During an interview 9/17/24 at 11:48 a.m. with Resident 1, Resident 1 stated she does not really ask anyone to help her call her bank, and she stated she does not go out with her friends. Resident 1 stated she would give her (credit) card to someone (staff) if they needed it [sic]. During a review of Resident 1 ' s (Name of Bank) Visa Signature Credit Card Statement, dated 4/3/24-5/2/24, the (Name of Bank) Visa Signature Credit Card Statement, indicated a charge on 4/11/24 at a grocery store for $132.13. During a review of the facility ' s Resident Sign in and out Sheets (record of residents going out of the facility), dated April 2024, the Resident Sign in and out Sheets indicated Resident 1 did not leave the facility in April 2024 to go to a grocery store to make purchases. During a review of Resident 1 ' s (Name of Bank) Visa Signature Credit Card Statement, dated 5/3/24-6/2/24, the (Name of Bank) Visa Signature Credit Card Statement, indicated the following charges: a) On 5/3/24, there was a charge at a gas station for $114.99. b) On 5/8/24, there was a charge at a grocery store for $225.30 and a grocery store for $37.38. c) On 5/22/24, there was a charge at a pizza place for $10.70. d) On 5/23/24, there was a charge at a gas station for $202.00. The total charges for May 2024 were $590.37. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056035 If continuation sheet Page 2 of 7 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 056035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shafter Nursing Care 140 East Tulare Avenue Shafter, CA 93263 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 During a review of Resident 1 ' s Inventory List (list of items resident possess), dated 2/28/23, the Inventory List indicated Resident 1 did not have a vehicle to get gas at a gas station. Level of Harm - Actual harm Residents Affected - Few During a review of the facility ' s Resident Sign in and out Sheets, dated May 2024, the Resident Sign in and out Sheets indicated Resident 1 did not leave the facility on 5/3/24, 5/8/24, 5/22/24, and 5/23/24 to make the purchases indicated in the above credit card statement. During a review of Resident 1 ' s (Name of Bank) Credit Card statement, dated 6/3/24-7/2/24, the (Name of Bank) Credit Card statement, indicated on 6/3/24 there was a charge at a dollar store for $40.86, another dollar store for $43.62, and a gas station for $303.00. During a review of the facility ' s Resident Sign in and out Sheets, dated June 2024, the Resident Sign in and out Sheets indicated Resident 1 did not leave the facility on 6/3/24 to go to a dollar store and to the gas station. During a review of Resident 1 ' s Statement of Accounts (Name of Bank) Member Advantage Checking (debit card), dated 6/17/24-7/16/24, the Statement of Accounts (Name of Bank) Member Advantage checking, indicated a cash back (a debit card transaction in which cardholders receive cash when they make a purchase) withdrawal on 7/16/24 of $35.00 at a dollar store. During a review of the facility ' s Resident Sign in and out Sheets, dated May 2024, the Resident Sign in and out Sheets indicated Resident 1 did not leave the facility on 6/3/24 and 7/16/24 to go to the dollar store and a gas station. During a review of Resident 1 ' s (Name of Bank) Visa Signature Credit Card Statement, dated 7/3/24-8/2/24 the (Name of Bank) Visa Signature Credit Card Statement, indicated the following charges: a) On 7/5/24, there was a charge at a dollar store for $ 59.19, another dollar store for $32.49, and a gas station for $422.59. b) On 7/13/24, there was a charge at a dollar store for $137.47, pharmacy for $37.53, and a gas station for $1,035.57. c) On 7/15/24, there was a charge at a dollar store for $57.86 and a gas station for $1,048.97. d) On 7/26/24, there was a charge at a dollar store for $ 151.99, dollar store for $55.33, and a gas station for $65.00. e) On 7/27/24, there was a charge at a grocery store for $12.56. f) On 7/29/24, there was a charge at a gas station for $69.78 and gas station for $1.99. g) On 7/30/24, there was a charge at a dollar store for $150.80. h) On 7/31/24, there was a charge at a gas station for $76.79, gas station for $29.85 and fast food for $42.19. The total charges for July 2024 were $3,487.95. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056035 If continuation sheet Page 3 of 7 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 056035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shafter Nursing Care 140 East Tulare Avenue Shafter, CA 93263 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 - Actual harm Residents Affected - Few During a review of the facility Resident Sign in and out Sheets, dated July 2024, the Resident Sign in and out Sheet indicated Resident [1] left the faciity on 7/10/24 for facility activity outing to a cinema. There was no documentation of Resident 1 going to a dollar store, grocery store, or a gas station in July 2024. During a review of Resident 1 ' s Statement of Accounts (Name of Bank) Member Advantage Checking, dated 7/17/24-8/16/24, the Statement of Accounts (Name of Bank) Member Advantage checking, indicated: a) On 8/5/24, there were cash back withdrawals and charges of $315.64 at a grocery store, $58.77 at a gas station, $284.00 at a clothing store, and $194.79 at a shoe store. b) On 8/6/24, there was a charge of $72.05 at a gas station During a review of Resident 1 ' s (Name of Bank) Visa Signature Credit Card Statement, dated 8/3/24-9/2/24, the (Name of Bank) Credit Card Statement, indicated the following charges: a) On 8/1/24, there was a charge at a gas station for $78.78 and clothing store for $179.54. b) On 8/2/24, there was a charge at a grocery store for $128.15 and a makeup store for $314.80. c) On 8/6/24, there was a charge at a dollar store for $91.99. d) On 8/11/24, there was a charge at a gas station for $70.00. e) On 8/14/24, there was a charge at a grocery store for $10.65. f) On 8/15/24, there was a charge at a gas station for $151.52, shoe store for $406.90, and shoe store for $200.25. g) On 8/17/24, there was a charge at gas station for $60.00. h) On 8/21/24, there was a charge at a Dollar store for $79.63 and dollar store for $182.32 and gas station for $74.74. The total charges for August 2024 were $2,029.27. During a review of Resident 1 ' s Statement of Accounts (Name of Bank) Member Advantage Checking, dated 8/17/24-9/16/24, the Statement of Accounts (Name of Bank) Member Advantage Checking, indicated on 8/19/24, there was a withdrawal $6,287.99 to transfer (payment) to Resident 1 ' s credit card. During an interview on 9/19/24 at 11:39 a.m. with AD, AD stated there were no outings in August due to the facility vehicle being broken down. During a review of the facility Resident Sign in and out Sheets, dated August 2024, the Resident Sign in and out Sheets indicated there were no documentation of Resident [1] left the facility in August 2024. During an interview on 9/17/24 at 12:23 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she works on the weekends on a rotating schedule and has not seen Resident 1 go out of the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056035 If continuation sheet Page 4 of 7 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 056035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shafter Nursing Care 140 East Tulare Avenue Shafter, CA 93263 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 with anyone during her (day) shifts. Level of Harm - Actual harm During an interview on 9/17/24 at 12:27 p.m. with CNA 2, CNA 2 stated she has not seen Resident 1 go out of facility on the weekends or with anyone during her shifts. Residents Affected - Few During a concurrent interview and record review on 9/17/24 at 12:45 p.m. with SSD, Resident 1 ' s Inventory List dated February 2023 was reviewed. The Inventory List indicated there was no documentation of additional items purchased since admission. SSD stated, The inventory list is supposed to be updated frequently anytime a resident gets something new, the item should be labeled with resident ' s name also. During an interview on 9/18/24 at 10:33 a.m. with Family Member (FM) 1, FM 1 stated, I received a call yesterday from [SSD] at 2:22 p.m., she [SSD] said there was an ongoing investigation regarding financial abuse, the cops came in, [SSD] was very defensive in our conversation, and it did not sit right. [SSD] also stated, ' your mother [Resident 1] likes to go shopping a lot and go out. ' That statement didn ' t sit right with me because I know my mother [Resident 1] and she [Resident 1] does not in fact like to go shopping, every time I talk with her [Resident 1] she asks me to send her [Resident 1] clothes and toiletries. So, I was thinking why she [Resident 1] is asking for these things if she [Resident 1] is going out all the time. FM 1 stated, My mother [Resident 1] does not know anyone at all in that area [facility location]. My brother and I live out of state we know no one there, and her [Resident 1] friends from [out of state] do not go down there to see her. I became suspicious a few months ago when I started getting alerts about her [Resident 1] credit card bill not being paid and her [Resident 1] regular recurrent charges for other bills not being paid and the balance jumping to $4,655. I tried to call the bank, but I was not a user anymore, but somehow, I still got the alerts. I was trying to get Power of Attorney [POA-a legal document that gives someone permission to act on behalf of another person] and had a conversation with [SSD] where she told me I could not get POA while my mom was at nursing home, so I stopped that process but I am really concerned and have a lot of red flags [something that indicates or draws attention to a problem, danger, or irregularity]. I have reached out to an attorney to assist. During an interview on 9/18/24 at 10:59 a.m. with Complainant, Complainant stated, I can verbally give you a list of transactions that stand out to me that are recent. Going back to April 2024 there is a [grocery store] for $132, May 2024 a [gas station] charge one transaction for $105 another for $202. A [grocery store] for over $300, June 4 2024 a [gas station] for $300, July 5 2024 a [dollar store], a [gas station] again for $422, July 13 2024 a [gas station] for $1035, July 13 2024 a [dollar store] for $113, August 1 2024 a [gas station], [clothing store] on August 2 2024 and [Makeup store] $315, August 6 2024 [dollar store], August 11 2024 [gas station], August 14 2024 [grocery store], August 15 2024 a [gas station] $151. There are more charges I can continue to compile a list. During an interview on 9/18/24 at 2:27 p.m. with SSD, SSD stated Resident 1 goes out shopping with her [SSD] and Activities Director (AD). SSD stated she got confused about Resident 1 going out on weekends, and SSD and AD take her shopping [clothing stores], [dollar store], [grocery store] and there is a shopping center with clothes and a couple shoe stores. SSD stated, I spoke with the daughter about the financial abuse allegation on Monday and yesterday morning before you guys [California Department of Public Health surveyors] got here. SSD stated she does not sign Resident [1] in and out even though she was supposed to. SSD stated Resident 1 did not give her the receipts (proof of purchase from the shopping expenses). During an interview on 9/19/24 at 11:39 a.m. with AD, AD stated she does take Resident 1 out on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056035 If continuation sheet Page 5 of 7 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 056035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shafter Nursing Care 140 East Tulare Avenue Shafter, CA 93263 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 - Actual harm Residents Affected - Few activity outings but there were no outings in August due to facility vehicle being broken down. AD stated she did not start signing Resident [1] in and out on the log until July (2024) when it was enforced. Resident [1] did attend outing in February to Walmart, May to Picnic in the park, June to Dewars [NAME] store and July to Cinema. AD stated she reported using personal vehicle one time with SSD to take Resident 1 to a dollar store. AD stated she does not recall the date when it took place, but it was a couple months ago, and she stated she did not obtain a receipt as the business office was not handling Resident 1 ' s funds. AD stated she has never taken Resident 1 to a gas station, and the only place outside of town they go to is Walmart in [out of town], she has never taken Resident 1 anywhere in [out of town] besides an approved activity outing. During an interview on 9/26/24 at 4:11 p.m. with Administrator, Administrator stated he was able to obtain bank records from Resident 1 ' s daughter and compare the records against Resident 1 ' s sign in and out logs which indicated Resident [1] had not been leaving the facility when the credit card was being used, and notified Police Department (PD) when they did not match and gave the PD the records. Administrator stated he suspended the SSD, visited local gas stations where the Resident 1 ' s credit card was used with photo of the SSD. Administrator stated he notified the PD on 9/19/24 or 9/20/24 who have begun an investigation. During an interview on 9/30/24 at 9:40 a.m. with Administrator, Administrator stated SSD was suspended on 9/18/24. Administrator stated they reviewed Resident 1 ' s inventory sheet from admission and looked at Resident [1 ' s] belongings she has in her room. Administrator stated Resident [1] does have a few clothing items but nothing they can identify with the amount of purchases on her credit card statements. Administrator stated they reviewed the statements and there are several concerning charges they cannot confirm Resident [1] authorized. Administrator stated they re-interviewed Resident 1 and Resident 1 does not recall going shopping or giving her credit card or debit card to anyone. Administrator stated Resident 1 ' s memory varies from day to day; Resident 1 cannot recall what she did the previous days. During an interview on 10/1/24, at 2:10 p.m. with Administrator in Training (AIT), AIT stated, We actually terminated [SSD] last Friday, 9/27/2024. Based on the evidence we collected and our investigation on our end we are confident that she was in fact the perpetrator based on the bank records of where the credit card was being used, there could have been no one else. During a review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, dated 2020, the P&P indicated, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and or misappropriation of resident property. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. During a review of the facility ' s Job Description-Social Services (JDSS), dated 2/21/22, the JDSS indicated, Essential Job Duties: Understand, comply with and promote all rules regarding resident rights, promote positive relationships with residents, visitors and regulators. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056035 If continuation sheet Page 6 of 7 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 056035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shafter Nursing Care 140 East Tulare Avenue Shafter, CA 93263 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview, and record review, the facility failed to report an allegation of financial abuse for one of three sampled residents (Resident 1) within 24 hours to the California Department of Public Health (CDPH) and complete a thorough investigation within five business days. This failure had the potential for Resident 1 experiencing continued financial abuse. Findings: During an interview on 9/17/24 at 11:18 a.m. with Social Services Director (SSD), SSD stated she called Resident 1 ' s bank and stated she pretended to be Resident 1 in order to reset (change) her pin number. SSD stated, Police Department [PD] came in last week or so, they pretty much just questioned who SSD and Administrator were. SSD stated on the weekends she [Resident 1] goes out with friends [unidentified] shopping. During an interview on 9/17/24 at 11:33 a.m. with Director of Nursing (DON), DON stated, PD came in last week, they spoke to resident [1] first then spoke to SSD, it was in regard to credit card fraud [wrongful or criminal deception intended to result in financial or personal gain]. During an interview on 9/17/24 at 1:09 p.m. with SSD, SSD stated she did not report the allegation of financial abuse to the CDPH. During an interview on 9/17/24 at 1:15 p.m. with DON, DON stated she did not report the allegation of financial abuse to the CDPH. During an interview on 9/17/24 at 1:22 p.m. with Administrator, Administrator stated he assisted Resident 1 in contacting her bank to reset her pin number on a video chat, then he heard there was some abuse going on and he spoke to everyone involved, SSD was working with Resident 1 prior to him assisting her (Resident 1). Administrator stated he was in the building when PD arrived but left and was interviewed by PD over the phone. Administrator stated he did not report the allegation of abuse to the CDPH. Administrator stated he did not check her (Resident 1) financial statements or any personal information. Administrator stated he was made aware of the financial abuse allegation when PD arrived in the building on 9/11/24. During a review of the facility ' s policy and procedure (P&P) titled, Abuse Investigation and Reporting, dated July 2017 the P&P indicated, All reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated. Findings of abuse investigations will also be reported. Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; 2. An alleged violation of abuse neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than b. twenty four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056035 If continuation sheet Page 7 of 7