Other·October 5, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of facility reported incident #CA00521006. Representing the Department of Public Health: HFEN, 32525 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 10/18/2018 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JK8F11 Facility ID: CA030000011 If continuation sheet 1 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055446 (X3) DATE SURVEY COMPLETED 09/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROCK CREEK CARE CENTER 260 Racetrack Street Auburn, CA 95603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JK8F11 Facility ID: CA030000011 If continuation sheet 2 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055446 (X3) DATE SURVEY COMPLETED 09/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROCK CREEK CARE CENTER 260 Racetrack Street Auburn, CA 95603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to protect the resident and to report allegations of abuse for 1 of 5 sampled residents (Resident 1) when: 1. A Certified Nursing Assistant 1 (CNA 1) was overheard questioning Resident 1 about allegations of abuse she had reported about CNA 1 and, 2. The allegation of abuse was not reported and a report of investigation sent to the Department in a timely manner. These failures had the potential to negatively impact Resident 1's psychosocial well-being. Findings: 1. According to the face sheet, the facility admitted Resident 1 over a year ago with multiple diagnoses including major depressive disorder. The most recent quarterly Minimum Data Set (MDS, an assessment tool) indicated she had no memory impairment. During an observation and concurrent interview with Resident 1 on 2/15/17 at 1:45 p.m., she verbalized CNA 1 had touched her room-mate inappropriately while putting her to bed the other night. Resident 1 stated she had told the family of her room-mate about it and CNA 1 had come to her room and accused her of lying about him to other people. Resident 1 stated CNA 1 was angry with her. When Resident 1 was asked if she felt safe at the facility, she stated, "Yes." When she was asked if she felt safe with CNA 1 she stated, "No" and indicated CNA 1 was no longer assigned to her. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JK8F11 Facility ID: CA030000011 If continuation sheet 3 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055446 (X3) DATE SURVEY COMPLETED 09/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROCK CREEK CARE CENTER 260 Racetrack Street Auburn, CA 95603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 2's progress note dated 1/28/17 documented by Licensed Nurse 1 (LN 1) indicated in part, "CNA [CNA 1] then went to resident's room to speak with resident's roommate [Resident 1] regarding the situation. Writer [LN 1] was on the medication cart 3 doors down when CNA was speaking to resident's room-mate; The majority of the content was inaudible, however, CNA was note [sic] yelling/shouting. Shortly after, resident's... [family member, FM] and her...approached writer, stating, 'That CNA, he needs to leave that room now. We're hearing what he's yelling to...(resident's room-mate) and he's bullying her! She's helpless! All he keeps saying to her is 'why did you say that about me? I didn't do that, you seriously get me in trouble.'" A review of Resident 1's progress note dated 1/30/17 indicated, "Alleged Abuse dated 1-2817: Spoke with resident about the incident that happened with her and a CNA which was witnessed by room-mate family-member. According to resident, CNA said to me 'you are liar, you getting me in trouble. Why you telling lie about me'. Resident stated 'I'm not lying. What I told...family what really happened...'" A review of the facility's Investigation Report dated 2/6/17 and faxed to the Department on 2/9/17 indicated CNA 1, "...confirmed the incident of him approaching [Resident 1] regarding allegations. He said he was only defending himself because he didn't want to get in trouble by management...Since staff member was visually seen by family member of verbally abusing resident, administrator and IDT [Interdisciplinary team] found it best to terminate employee and end his relationship with the building." During an interview with FM on 2/21/17 at 9:53 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JK8F11 Facility ID: CA030000011 If continuation sheet 4 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055446 (X3) DATE SURVEY COMPLETED 09/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROCK CREEK CARE CENTER 260 Racetrack Street Auburn, CA 95603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a.m., she stated she and her spouse witnessed the incident while they visited Resident 2, a room-mate to Resident 1. FM stated that on the afternoon of 1/28/17, she overheard CNA 1 telling Resident 1, "You are a liar...why are you lying about me...trying to get me in trouble..." FM reported Resident 1 looked fearful and kept verbalizing to CNA 1 she had not lied about him. FM stated CNA 1 repeatedly told Resident 1 that she had lied about him and at that point FM's spouse pulled CNA 1 out of the room. During an interview with LN 1 on 2/22/17 at 4:20 p.m., she stated on 1/28/17 starting from 4 p.m., she was giving medications about 5 doors away from Resident 1's room. LN 1 stated FM approached her and was in tears. LN 1 stated FM told her she wanted CNA 1, "Out of my mothers's room [Resident 2] right now." LN 1 stated she saw FM's spouse standing at the doorway of Resident 1's room and over-heard him saying, "Young man, you need to get out of here." LN 1 then saw CNA 1 leaving Resident 1's room and walked towards the nurses' station. LN 1 stated she later spoke to CNA 1 on 1/28/17 at around 7 p.m. about the incident and CNA 1 told her he had gone to Resident 1's room to question her about telling people he had touched her room-mate inappropriately, which was a lie. A review of the facility's daily staff assignment indicated CNA 1 was assigned to provide care to Resident 1 and Resident 2 on 1/27/17 and in a section in or near their room on 1/28/17 and 1/29/17. A review of the facility's policy dated as revised 4/2014 and titled 'Abuse Investigations' indicated, "All reports of resident abuse,...shall be thoroughly investigated by facility management...Employees of this facility who have been accused of resident abuse will be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JK8F11 Facility ID: CA030000011 If continuation sheet 5 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055446 (X3) DATE SURVEY COMPLETED 09/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROCK CREEK CARE CENTER 260 Racetrack Street Auburn, CA 95603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE suspended immediately pending the outcome of the investigation..." During an interview with the Administrator on 2/23/17 at 1:04 p.m., when he was asked what his expectations were regarding CNA 1 confronting Resident 1 for reporting an incident of alleged abuse, the administrator stated, "The CNA was unprofessional and inappropriate." 2. A review of the report received by the Department indicated the alleged incident occurred on 1/28/17 and was not received by the Department until 2/3/17, 5 days later. A review of the facility's policy dated as revised 4/2007 and titled 'Abuse and Neglect- Clinical Protocol' directed, "The management and staff , with the support of the physicians, address, situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations." The policy did not include the time frame for reporting abuse allegations to the Department as required by law. A review of another facility's policy dated as revised 4/2014 and titled 'Abuse Investigations' indicated, "All reports of resident abuse,...shall be thoroughly investigated by facility management...Employees of this facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation...The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by sate or local laws, within five (5) working days of the reported incident." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JK8F11 Facility ID: CA030000011 If continuation sheet 6 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055446 (X3) DATE SURVEY COMPLETED 09/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROCK CREEK CARE CENTER 260 Racetrack Street Auburn, CA 95603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with the Administrator on 2/23/17 at 1:04 p.m., he validated the allegations of abuse were not reported to the Department in a timely manner. The Administrator indicated LN 1 should have sent a report of the alleged abuse to the Department (State Agency) and notified the Administrator. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JK8F11 Facility ID: CA030000011 If continuation sheet 7 of 7