Health inspection·July 9, 2025

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of personal property when Dietary Aide (DA) 1 agreed to withdraw cash and purchase cigarettes with the use of the resident's debit card for one of three sampled residents (Resident 1). This failure resulted in $8,000 worth of unauthorized cash withdrawals from Resident 1's bank account within a four-day span. This failure also violated Resident 1's right to be free from misappropriation and placed other residents at risk for similar exploitation. Cross-reference F609 and F610. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one entire side of the body) following a cerebral infarction (an interruption in blood flow to the brain), muscle weakness, and depression (persistent feeling of sadness). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 5/9/2025, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 1 required partial to moderate assistance (helper does less than half of the effort) for toileting hygiene, bathing, and required supervision when performing oral hygiene, dressing, and personal hygiene. During a review of Resident 1's History and Physical (H&P), dated 5/29/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of the facility's SOC 341 (a report of suspected dependent adult or elder abuse), dated 7/7/2025, the form indicated the facility reported an allegation of elderly financial abuse on 7/7/2025. The form indicated Resident 1 reported he gave his debit card with the pin number written on an envelope to somebody to withdraw money from his account. The form indicated Resident 1 reported more funds were withdrawn than originally requested and were missing. During a review of Licensed Vocational Nurse (LVN) 1's written statement, dated 7/9/2025, the written statement indicated on 6/28/2025, Resident 1 came out of his room yelling, That motherfuck-stole my money! The statement indicated LVN 1 followed Resident 1 to the kitchen and Resident 1 pointed at Dietary Aide (DA) 1 and stated, It was that guy! The statement indicated DA 1 stated, It wasn't me, my car has been in the shop! Resident 1 explained that he lent his debit card to DA 1 about a week ago so that DA 1 could buy cigarettes for him, and the card was supposed to be returned the same day. The statement indicated DA 1 repeatedly stated his car had been in the shop for a week. The statement indicated LVN 1 proceeded to assist Resident 1 to speak with a bank representative as LVN 1 hand wrote the amounts withdrawn from Resident 1's bank account (as dictated by the bank representative). The statement indicated RN 1 informed the Director of Nursing (DON) of the situation. The statement indicated RN 1 informed LVN 1 that the DON would notify the Administrator (ADM). During an interview on 7/8/2025 at 10:30 a.m. with ADM, the ADM stated DA 1 was suspended on 7/7/2025. During an interview on 7/8/2025 at 10:47 p.m. with Resident 1, Resident 1 stated on 6/25/2025, he provided DA 1 with his Residents Affected - Few Page 1 of 9 056415 056415 07/09/2025 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few debit card and the pin number in an envelope. Resident 1 stated he asked DA 1 to withdraw $100 and buy him (Resident 1) a pack of cigarettes. Resident 1 stated DA 1 returned with two packs of cigarettes and $50. Resident 1 stated when he asked DA 1 for his card back, DA 1 replied the card was in his vehicle. Resident 1 stated he did not report the incident on 6/25/2025 but attempted to speak with DA 1 (6/26/2025), but DA 1 was off duty. Resident 1 stated on 6/27/2025, DA 1 told the resident the debit card was inside of his vehicle. Resident 1 stated DA 1 finally returned the debit card on 6/28/2025. Resident 1 stated he immediately called the bank with the help of LVN 1 to verify the funds in his account. Resident 1 stated he was surprised to learn that $2,000 was withdrawn each day from 6/25/2025 through 6/28/2025, which totaled $8,000. Resident 1 stated this made him so mad that he went to the kitchen, confronted DA 1, and yelled. Resident 1 stated DA 1 remained silent, refused to provide an explanation, and wore a dumb look on his face. Resident 1 stated LVN 1 and RN 1 told him to address the matter on 6/30/2025. Resident 1 stated on 6/30/2025, he made Social Services Director (SSD) 1 aware of the situation and SSD 1 helped Resident 1 file a claim with the bank. Resident 1 stated SSD 1 helped call the police on 7/1/2025. During an interview on 7/8/2025 at 11:13 a.m. with SSD 1, SSD 1 stated on 6/30/2025, Resident 1 reported he provided his debit card and pin number to DA 1 and money was missing. SSD 1 stated she assisted Resident 1 file a claim for the missing money. SSD 1 stated on 7/1/2025, she called the police. SSD 1 stated staff were not allowed to accept a resident's personal debit card to perform cash withdrawals or to purchase items without the presence of the resident. SSD 1 stated she expected staff to defer the request to her and she would verify if the resident had a family member or a representative party that could perform the transaction or assist the resident. SSD 1 stated another option was to arrange a qualified staff member to accompany the resident to the bank or the automated teller machine (ATM). SSD 1 stated the incident was considered misappropriation or financial abuse. During a telephone interview on 7/8/2025 at 11:57 p.m. with DA 1, DA 1 stated Resident 1 provided him a thick envelope with Resident 1's debit card and pin number. DA 1 stated Resident 1 requested for him to withdraw $100 and purchase a pack of cigarettes. During an interview on 7/8/2025 at 12:17 p.m. with LVN 1, LVN 1 stated on 6/28/2025, Resident 1 was angry and hurriedly made his way out of his room towards the kitchen. LVN 1 stated she followed Resident 1. LVN 1 stated DA 1 came out of the kitchen to explain Resident 1 gave DA 1 his personal debit card and pin number to buy Resident 1 cigarettes. LVN 1 stated Resident 1 alleged DA 1 kept his debit card for about a week. LVN 1 stated DA 1 explained the debit card was inside of his car which had been at the mechanic shop. LVN 1 stated at that point, RN 1 intervened and told both Resident 1 and DA 1 to stop. LVN 1 stated she assisted Resident 1 back to his room and called the bank. LVN 1 stated she transcribed the amount of money withdrawn from Resident 1's account from 6/25/2025 through 6/28/2025 (total of $8,000). LVN 1 stated staff were not allowed to accept resident's debit cards for any purpose because it had the potential to lead to financial abuse and situations like this. LVN 1 stated DA 1's possession of Resident 1's debit card and the confirmation of missing funds from Resident 1's bank account constituted suspicion of financial abuse. During an interview on 7/8/2025 at 12:57 p.m. with RN 1, RN 1 stated on duty on 6/28/2025 Resident 1 and DA 1 had a confrontation in the doorway of the kitchen. RN 1 stated she intervened and asked DA 1 to step away and stop. RN 1 stated she proceeded to call and text the DON to inform him Resident 1 gave his debit card to DA 1 to buy cigarettes, and when Resident 1's bank was contacted money was missing. RN 1 stated DA 1 should have never taken Resident 1's debit card because funds can go missing and there was a potential for financial abuse. RN 1 stated Resident 1's allegation was suspicious for misappropriation of funds. During an interview on 7/8/2025 at 1:30 p.m. with the ADM, the ADM stated DA 1's actions did not align 056415 Page 2 of 9 056415 07/09/2025 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with the facility's policy because staff were not permitted to handle personal banking transactions with a resident's debit card. The ADM stated it was the facility's responsibility to ensure residents' property was not misplaced or stolen. The ADM stated staff were not permitted to take resident's debit cards in order to protect the resident from any form of financial abuse and to make sure instances like this do not happen again. During an interview on 7/9/2025 at 11:40 a.m. with a representative from Resident 1's bank (Bank Representative 1), Bank Representative 1 confirmed $2,000 was withdrawn each day from 6/25/2025 through 6/28/2025, totaling $8,000. During a review of the facility's Policy and Procedure (P&P), titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/2021, the P&P indicated residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. During a review of the facility's P&P, titled, Resident Rights, revised 2/2021, the P&P indicated the facility would ensure the resident would remain free from abuse, neglect, misappropriation of property and exploitation. During a review of the Dietary Aide Job Description (undated), indicated the following: 1. The dietary aide would be committed to always doing the right thing.2. The dietary aide would adhere to all facility policies and procedures. 056415 Page 3 of 9 056415 07/09/2025 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one out of three sampled residents (Resident 1) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 reported to the California Department of Health (CDPH), ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local authorities within 2 hours on 6/28/2025, after being made aware Dietary Aide (DA 1) was in possession of Resident 1's debit card from 6/25/2025 through 6/28/2025 and a total of $8,000 dollars was withdrawn from Resident 1's bank account without Resident 1's knowledge. 2. Ensure Social Services Designee (SSD) 1 reported to the CDPH, ombudsman, and local authorities on 6/30/2025, when she was first made aware of Resident 1's allegation of misappropriation (illegal use of someone else's money for purposes other than those intended by the rightful owner) of personal funds.3. Ensure Registered Nurse (RN) 1 reported a suspicion of misappropriation of personal funds within 2 hours to the CDPH, ombudsman, and local authorities on 6/28/2025, when RN 1 was made aware Resident 1's funds were missing. These failures resulted in a delay of investigation by CDPH and law enforcement and had the potential to lead to further financial abuse by DA 1 to other residents.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one entire side of the body) following a cerebral infarction (an interruption in blood flow to the brain), muscle weakness, and depression (persistent feeling of sadness). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 5/9/2025, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 1 required partial to moderate assistance (helper does less than half of the effort) for toileting hygiene, bathing, and required supervision when performing oral hygiene, dressing, and personal hygiene. During a review of the facility's SOC 341 (a report of suspected dependent adult or elder abuse), dated 7/7/2025, the form indicated the facility reported an allegation of elderly financial abuse on 7/7/2025. The form indicated Resident 1 reported he gave his debit card with the pin number written on an envelope to somebody to withdraw money from his account. The form indicated Resident 1 reported more funds were withdrawn than originally requested and were missing. 1. During a review of Licensed Vocational Nurse (LVN) 1's written statement, dated 7/9/2025, the statement indicated on 6/28/2025, Resident 1 came out of his room yelling That motherfuck-- stole my money! The statement indicated LVN 1 followed Resident 1 to the kitchen and Resident 1 pointed at Dietary Aide (DA) 1 and stated, It was that guy! The written statement indicated DA 1 stated, It wasn't me my car has been in the shop! Resident 1 explained that he lent his debit card to DA 1 about a week ago so that DA 1 could buy cigarettes for him, and the card was supposed to be returned the same day. The statement indicated DA 1 repeatedly stated his car had been in the shop for a week. The statement indicated RN 1 informed the Director of Nursing (DON) and informed LVN 1 that the DON would notify the Administrator (ADM). During an interview on 7/8/2025 at 10:47 p.m. with Resident 1, Resident 1 stated on 6/25/2025, he provided DA 1 with his debit card and the pin number in an envelope. Resident 1 stated he asked DA 1 to withdraw $100 and buy him (Resident 1) a pack of cigarettes. Resident 1 stated DA 1 returned with two packs of cigarettes and $50. Resident 1 stated the other $50 was missing and when Resident 1 asked DA 1 for his card back, DA 1 responded by stating the card was in DA 1's vehicle. Resident 1 stated DA 1 did not return Resident 1's debit card and the 056415 Page 4 of 9 056415 07/09/2025 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few remaining $50. Resident 1 stated he did not report the incident on 6/25/2025 and attempted to speak with DA 1 the following day (6/26/2025) but DA 1 was off duty. Resident 1 stated on 6/27/2025, DA 1 stated the debit card was inside of his vehicle and returned on 6/28/2025. Resident 1 stated he immediately called the bank with the help of LVN 1 to verify the funds in his account. Resident 1 stated he was surprised to learn that $2,000 was withdrawn each day from 6/25/2025 through 6/28/2025, which totaled $8,000. Resident 1 stated this made him so mad that he went to the kitchen, confronted DA 1, and yelled. Resident 1 stated DA 1 remained silent, refused to provide an explanation, and wore a dumb look on his face. Resident 1 stated LVN 1 and RN 1 told him to address the matter on 6/30/2025. Resident 1 stated on 6/30/2025, he made Social Services Director (SSD) 1 aware of the entire situation the morning of 6/30/2025 and SSD 1 helped Resident 1 file a claim with the bank. Resident 1 stated SSD 1 helped call the police on 7/1/2025. 2. During an interview on 7/8/2025 at 11:13 a.m. with SSD 1, SSD 1 stated on 6/30/2025, Resident 1 reported he provided his debit card and pin number to DA 1 and money was missing. SSD 1 stated for any instances of alleged or suspected financial abuse or misappropriation, the expectation was to report to the ombudsman, local authorities, the ADM, and CDPH. SSD 1 stated the incident had the potential to be considered as financial abuse. SSD 1 stated on 6/30/2025, SSD 1 reported the allegation to the ADM, but did not notify the local authorities until 7/1/2025, and did not notify the ombudsman or CDPH. SSD 1 stated all staff were mandated reporters, and she should have reported the incident to the ombudsman, CDPH, and local authorities 6/30/2025. SSD 1 stated she did not do so because she thought the ADM would notify the proper agencies. SSD 1 stated it was important to notify the local authorities, the ombudsman, and CDPH right away to prevent further potential financial abuse from occurring. During a telephone interview on 7/8/2025 at 11:57 p.m. with DA 1, DA 1 stated Resident 1 provided him a thick envelope with Resident 1's debit card and pin number. DA 1 stated Resident 1 requested for him to withdraw $100 and purchase a pack of cigarettes. During an interview on 7/8/2025 at 12:17 p.m. with LVN 1, LVN 1 stated on 6/28/2025, Resident 1 was angry and hurriedly made his way out of his room towards the kitchen. LVN 1 stated she followed Resident 1. DA 1 came out of the kitchen to explain Resident 1 gave DA 1 his debit card and pin number to buy cigarettes. LVN 1 stated Resident 1 alleged DA 1 kept his debit card for about a week. LVN 1 stated DA 1 explained the debit card was inside of DA 1's car, which had been at the mechanic shop. LVN 1 stated she assisted Resident 1 back to his room and assisted Resident 1 with calling the bank. LVN 1 stated she transcribed the amounts of money that was withdrawn each day from 6/25/2025 through 6/28/2025 (total of $8,000). LVN 1 stated DA 1's possession of Resident 1's debit card and the confirmation of missing funds from Resident 1's bank account constituted suspicion of financial abuse, which should have been reported to the local authorities, the ombudsman, and CDPH within two hours on 6/28/2025. LVN 1 stated all staff were considered mandated reporters and she should have reported to the local authorities, the ombudsman, and CDPH as soon as possible, but did not do so because she was under the impression that RN 1 or the DON would report to the proper agencies. 3. During an interview on 7/8/2025 at 12:57 p.m. with RN 1, RN 1 stated on 6/28/2025 Resident 1 and DA 1 had a confrontation in the doorway of the kitchen. RN 1 stated she intervened and asked DA 1 to step away and stop. RN 1 stated she proceeded to call and text the DON to inform him Resident 1 gave his debit card to (DA 1) to buy cigarettes and when Resident 1's bank was contacted, money was missing. RN 1 stated DA 1 should have never taken Resident 1's debit card because funds can go missing and there was a potential for financial abuse. RN 1 stated all staff members were mandated reporters and for any allegation or suspicion of financial abuse or misappropriation, the local authorities, CDPH and the ombudsman should be notified immediately. RN 1 stated Resident 1's allegation was 056415 Page 5 of 9 056415 07/09/2025 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few suspicious for misappropriation of funds, and she should have reported the allegation to the local authorities, CDPH and the ombudsman. RN 1 stated she did not do so because she notified the DON, and the DON informed her that he would notify the ADM. RN 1 stated she told Resident 1 that SSD 1 would handle the matter on 6/28/2025. During an interview on 7/8/2025 at 1:30 p.m. with the ADM, the ADM stated the normal process for reporting any allegation of abuse was to report to CDPH, ombudsman, the police and complete the SOC 341 within two hours. The ADM stated it was important to report timely so an investigation could start, and to prevent further instances of abuse. The ADM stated LVN 1 informed RN 1 of the incident, and RN 1 informed the DON on 6/28/2025. The ADM stated she did not report the incident because she was out of the country on vacation and did not view the DON's message on 6/28/2025. The ADM stated she was made aware of the complete details of the situation on 7/7/2025 after Resident 1 reported the incident to her. The ADM stated LVN 1 and RN 1 should have reported the incident on 6/28/2025 to CDPH, the ombudsman, and the police. The ADM stated the delay in the reporting of the incident led to a delay in the initiation of an investigation. The ADM stated the lack of timely reporting placed Resident 1 at risk for further financial abuse by DA 1 (from 6/28/2025 through 7/7/2025). During an interview on 7/8/2025 at 3:08 p.m. with the DON, the DON stated he was out of the country on 6/28/2025 and returned to work on 6/30/2025. The DON stated RN 1 informed him of Resident 1's missing funds. The DON stated the police were notified on 7/1/2025. The DON stated immediate actions should have been taken to report to CDPH and the ombudsman of the incident. During a review of the facility's Policy and Procedure (P&P), titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 9/2022, the P&P indicated the following: 1. All reports of resident abuse (including injuries of unknown origin) or theft or misappropriation of resident property are reported to local, state- and federal agencies (as required by current regulations).2. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.3. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility;b. The local/state ombudsman;c. The resident's representative;d. Adult protective services (where state law provides jurisdiction in long-term care);e. Law enforcement officials;f. The resident's attending physician; andg. The facility medical director.4. Immediately is defined as:a. within two hours of an allegation involving abuse or result in serious bodily injury; orb. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 056415 Page 6 of 9 056415 07/09/2025 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one out of three sampled residents (Resident 1) by failing to initiate and conduct a timely investigation into an allegation of misappropriation of resident property and missing funds when the following occurred: 1. Licensed Vocational Nurse (LVN) 1 was made aware on 6/28/2025, of an allegation that Dietary Aide (DA 1) was in possession of Resident 1's debit card from 6/25/2025 through 6/28/2025 and a total of $8,000 in unauthorized cash withdrawals from Resident 1's bank account occurred from 6/25/2025 through 6/28/2025. 2. Registered Nurse (RN) 1 was made on 6/28/2025 Resident 1's debit card and funds were missing. 3. Social Services Designee (SSD) 1 was made aware, on 6/30/2025, Resident 1's funds were missing. These failures resulted in a delay of protective measures for Resident 1. This failure also resulted in a delay of disciplinary action against DA 1 which had the potential to lead to further financial abuse by DA 1 to other residents.Cross reference F602 and F609Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one entire side of the body) following a cerebral infarction (an interruption in blood flow to the brain), muscle weakness, and depression (persistent feeling of sadness) During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 5/9/2025, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 1 required partial to moderate assistance (helper does less than half of the effort) for toileting hygiene, bathing, and required supervision when performing oral hygiene, dressing, and personal hygiene. During a review of the facility's SOC 341 (a report of suspected dependent adult or elder abuse), dated 7/7/2025, the form indicated the facility reported an allegation of elderly financial abuse on 7/7/2025. The form indicated Resident 1 reported he gave his debit card with the pin number written on an envelope to somebody to withdraw money from his account. The form indicated Resident 1 reported more funds were withdrawn than originally requested, and the funds were missing. 1. During a review of Licensed Vocational Nurse (LVN) 1's written statement, dated 7/9/2025, the written statement indicated, on 6/28/2025, Resident 1 came out of his room, yelling, That motherfuck-- stole my money! The statement indicated Licensed Vocational Nurse (LVN) 1 followed Resident 1 to the kitchen and Resident 1 pointed at Dietary Aide (DA) 1 and stated, It was that guy! The statement indicated DA 1 replied, It wasn't me, my car has been in the shop! Resident 1 explained that he lent his debit card to DA 1 about a week ago so that DA 1 could buy cigarettes for him, and the card was supposed to be returned the same day. The statement indicated DA 1 repeatedly stated his car had been in the shop for a week. The statement indicated LVN 1 proceeded to assist Resident 1 to speak to a representative from his bank and LVN 1 hand wrote the amounts withdrawn from Resident 1's bank account (as dictated by the bank representative). The statement indicated RN 1 made the Director of Nursing (DON) aware of the situation and RN 1 informed LVN 1 that the DON would notify the Administrator (ADM). During an interview on 7/8/2025 at 10:47 p.m. with Resident 1, Resident 1 stated on 6/25/2025, he provided DA 1 with his debit card and the pin number in an envelope. Resident 1 stated he asked DA 1 to withdraw $100 and buy him (Resident 1) a pack of cigarettes. Resident 1 stated DA 1 returned with two packs of cigarettes and $50. Resident 1 stated when he asked DA 1 for his card back, DA 1 responded by stating the card was in DA 1's vehicle. Resident 1 stated DA 1 did not return Resident 1's debit card and the remaining $50. Resident 1 stated he did not report the incident on 6/25/2025. Residents Affected - Few 056415 Page 7 of 9 056415 07/09/2025 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 stated he attempted to speak with DA 1 the following day (6/26/2025), but DA 1 was on duty. Resident 1 stated on 6/27/2025, DA 1 stated the debit card was inside of his vehicle. Resident 1 stated DA 1 finally returned the debit card on 6/28/2025. Resident 1 stated he immediately called the bank with the help of LVN 1 to verify the funds in his bank account. Resident 1 stated he was surprised to learn that $2,000 was withdrawn each day from 6/25/2025 through 6/28/2025, which totaled $8,000. Resident 1 stated this made him so mad that he went to the kitchen, confronted DA 1, and yelled. Resident 1 stated DA 1 remained silent, refused to provide an explanation, and wore a dumb look on his face. Resident 1 stated LVN 1 and RN 1 told him to address the matter on 6/30/2025. Resident 1 stated, on 6/30/2025, he made Social Services Director (SSD 1) aware of the entire situation and SSD 1 helped Resident 1 file a claim with his bank. Resident 1 stated SSD 1 helped call the police on 7/1/2025. 2. During an interview on 7/8/2025 at 11:13 a.m. with SSD 1, SSD 1 stated on 6/30/2025, Resident 1 reported he provided his debit card and pin number to DA 1 and was missing money. SSD 1 stated she proceeded to assist Resident 1 with filing a claim for the missing money with the bank. SSD 1 stated she called the police on 7/1/2025.SSD 1 stated staff were not allowed to accept a resident's debit card to perform a cash withdrawal or to purchase items without the presence of the resident. SSD 1 stated she expected staff to defer the request to SSD 1 and she would verify if the resident had a family member or a responsible party that could perform the transaction or assist the resident. SSD 1 stated another option was to arrange a qualified staff member to accompany the resident to the bank or the automated teller machine (ATM). SSD 1 stated for any instances of alleged or suspected financial abuse or misappropriation, the expectation was to report to the ombudsman, local authorities, the ADM, and California Department of Public Health (CDPH). SSD 1 stated the incident had the potential to be considered as financial abuse. SSD 1 stated on 6/30/2025, SSD 1 reported the allegation to the ADM, but did not notify the local authorities until 7/1/2025, and never notified the ombudsman or CDPH. SSD 1 stated every staff member of the facility was a mandated reporter, and she should have reported the incident to the ombudsman, CDPH, and local authorities as soon as she gained knowledge of the incident on 6/30/2025. SSD 1 stated she did not do so because she thought the ADM would notify the proper agencies. SSD 1 stated it was important to notify the local authorities, the ombudsman, and CDPH right away to prevent further potential financial abuse from occurring. 3. During an interview on 7/8/2025 at 12:57 p.m. with RN 1, RN 1 stated on 6/28/2025 Resident 1 and DA 1 had a confrontation in the doorway of the kitchen. RN 1 stated she intervened and asked DA 1 to step away and stop. RN 1 stated she did not suspend DA 1 for the remainder of his shift. RN 1 stated she proceeded to call and text the DON to inform him Resident 1 gave his debit card to DA 1 to buy cigarettes and money was missing after contacting Resident 1's bank. RN 1 stated all staff members were mandated reporters and for any allegation or suspicion of financial abuse or misappropriation, the local authorities, CDPH and the ombudsman should be notified immediately because the incident needed to be investigated. During an interview on 7/8/2025 at 1:30 p.m. with the ADM, the ADM stated the normal process for reporting any allegation of abuse was to report to CDPH, ombudsman, the police and complete the SOC 341 within two hours. The ADM stated it was important to report timely so an investigation could start, and to prevent further instances of abuse. The ADM stated she was made aware of the complete details of the situation on 7/7/2025 after Resident 1 reported the incident to her. The ADM stated the delay in reporting the incident led to a delay in the initiation of an investigation and the suspension of DA 1. The ADM stated all staff members that had knowledge of Resident 1's allegation of misappropriation should have reported to her directly so that she could have initiated a timely investigation. The ADM stated the lack of a timely investigation placed Resident 1 and other 056415 Page 8 of 9 056415 07/09/2025 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents at risk for further financial abuse by DA 1 (from 6/28/2025 through 7/7/2025). During an interview on 7/8/2025 at 3:08 p.m. with the DON, the DON stated he was out of the country on 6/28/2025 and returned to work on 6/30/2025. The DON stated RN 1 made him aware Resident 1 was missing funds from his bank account. The DON stated he should have ensured the ADM received his message about the incident so that a timely investigation could have been initiated to identify and suspend the staff involved in the allegation. During a review of the facility's P&P, titled, Personal Property, revised 8/2022, the facility promptly investigates any complaints of misappropriation of property. During a review of the facility's Policy and Procedure (P&P), titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 9/2022, the P&P indicated all reports of resident abuse (including injuries of unknown origin) or theft or misappropriation of resident property are and thoroughly investigated by facility management. Findings of all investigations are documented and reported. 056415 Page 9 of 9