Other·February 19, 2019

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 #CA00605084. Representing the Department of Public Health: HFEN, 36738 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility.

F606 SS=D Not Employ/Engage Staff w/ Adverse Actions CFR(s): 483.12(a)(3)(4)

F606 03/01/2019 §483.12(a) The facility must§483.12(a)(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, neglect, exploitation, mistreatment of residents or misappropriation of resident property. §483.12(a)(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. 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: MUNK11 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 01/21/2019 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to protect residents from possible abuse when they knowingly employed a Licensed Nurse 1 (LN 1) who had been found guilty of abuse and has a disciplinary action against his professional license for a census of 77. This failure put residents in the facility at risk for abuse. Findings: On 10/5/18 an unannounced visit was conducted to investigate a facility reported incident related to an abuse allegation. LN 1 was accused of verbally abusing a resident. Upon review of LN 1's employee file, the LN 1 was hired on 5/7/15. The file failed to contain documented evidence of a pre-employment background screening, and reference checks. During a review of LN 1's License Verification with the California State Board of Licensing, LN 1's license indicated: Secondary Status: Probation Disciplinary Actions, Start: June 16, 2016, Action: Revocation of the license is stayed pending successful completion of probation. Start: August 8, 2014: Action: A formal statement of charges filed against a licensee. Start: April 12, 1996: Action: A formal statement of charges filed against a licensee. This indicated the LN had been formally charged with allegations of abuse, and his license would be revoked if the LN did not successfully complete probation. LN 1 was on probation for multiple "Cause For FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MUNK11 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 01/21/2019 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 Discipline" findings including: Mistreatment of a Patient (yelling at 2 patients, aggressively, and threatening a patient) Failure to Maintain Professional Boundaries with 2 Patients Unprofessional Conduct Mistreatment of a Patient Dishonesty (failure to disclose LN 1 had been terminated for sexual misconduct, verbal abuse) During an interview with the Director of Nurses (DON) at 1 p.m., the DON stated that he did not hire LN 1 but had "inherited him". The DON further stated that LN 1 was still working in the facility and "we are aware of his probation status." In an interview with the Director of Staff Development (DSD) and the Human Resources representative (HR) on 10/5/18 at 2:40 p.m., the DSD stated the process of hiring an employee involves a background check and reference check. The HR confirmed that the process is to run a background check and to check references on employees. Both the HR and the DSD confirmed there was no background check or reference check in LN 1's employee file. Review of the facility's Policy and Procedure titled "Employee Selection and Hiring", dated 6/1/11...Each applicant's references must be checked...The company performs a post-offer, pre-employment background check on all candidates. Review of the facility's Policy and procedure titled, "Preventing Resident Abuse", revised date January 2011, ...Conducting background investigations to avoid hiring persons...who have been found guilty (by a court of law) of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MUNK11 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 01/21/2019 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 abusing, neglecting or mistreating individuals or those who have had a finding of such action entered into the state nurse aide registry or state sex offender registry. During an interview with the Administrator (ADM) on 10/11/18 at 4:30 p.m., the ADM admitted they did not have the documentation of a background screening or reference checks for LN 1.

F607 SS=D Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 03/01/2019 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MUNK11 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 01/21/2019 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 paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to implement their policies an procedures for screening new employees when the facility hired an employee without completing a criminal background screen, and checking references for a census of 77. This failure resulted in the facility hiring a Licensed Nurse who was on probation with the nursing board for findings of abuse with disciplinary action against his license. Findings: On 10/5/18 an unannounced visit was conducted to investigate a facility reported incident related to an abuse allegation. Licensed Nurse 1 (LN 1) was accused of verbally abusing a resident. Upon review of LN 1's employee file, the LN 1 was hired on 5/7/15. The file failed to contain documented evidence of a pre-employment background screening, reference checks and a completed employee application. During a review of LN 1's License Verification with the California State Board of Licensing, LN 1's license indicated: Secondary Status: Probation Disciplinary Actions, Start: June 16, 2016, Action: Revocation of the license is stayed pending successful completion of probation. Start: August 8, 2014: Action: A formal statement of charges filed against a licensee. Start: April 12, 1996: Action: A formal statement of charges filed against a licensee. This indicated the LN had been formally FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MUNK11 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 01/21/2019 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 charged with allegations of abuse, and his license would be revoked if the LN did not successfully complete probation. LN 1 was on probation for multiple "Cause For Discipline" findings including: Mistreatment of a Patient (yelling at 2 patients, aggressively, and threatening a patient) Failure to Maintain Professional Boundaries with 2 Patients Unprofessional Conduct Mistreatment of a Patient Dishonesty (failure to disclose LN 1 had been terminated for sexual misconduct, verbal abuse) Upon review of LN 1's employee file, the LN 1 was hired on 5/7/15. The file failed to contain documented evidence of a pre-employment background screening, reference checks and a completed employee application. In an interview with the Director of Staff Development (DSD) and the Human Resources representative (HR) on 10/5/18 at 2:40 p.m., the DSD stated the process of hiring an employee involves a background check and reference check. The HR confirmed that the process is to run a background check and to check references on employees. Both the HR and the DSD confirmed there was no background check or reference check in LN 1's employee file. Review of the facility's Policy and Procedure titled "Employee Selection and Hiring", dated 6/1/11...Each applicant's references must be checked...The company performs a post-offer, pre-employment background check on all candidates. Review of the facility's Policy and procedure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MUNK11 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 01/21/2019 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 titled, "Preventing Resident Abuse", revised date January 2011, ...Conducting background investigations to avoid hiring persons...who have been found guilty (by a court of law) of abusing, neglecting or mistreating individuals or those who have had a finding of such action entered into the state nurse aide registry or state sex offender registry. During an interview with the Administrator (ADM) on 10/11/18 at 4:30 p.m., the ADM admitted they did not have the documentation of a background screening or reference checks for LN 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MUNK11 Facility ID: CA030000011 If continuation sheet 7 of 7