Inspection Reports for
Rock Creek Senior Living
3602 NW 5th Street, Ankeny, IA, 50023
Back to Facility Profile7 Reports
Inspection Report — Oct 2, 2025
Renewal
Date: Oct 2, 2025
Visit Reason
The visit was a recertification (renewal) visit to determine compliance with certification of an Assisted Living Program for People with Dementia. The investigation also covered Incident #129931-I and Complaint #129332-C.
Complaint Details
Incident #129931-I and Complaint #129332-C were investigated during this visit.
Findings
Two regulatory insufficiencies were cited related to individualized service plans and emergency policies regarding alarm systems. The program failed to ensure service plans were individualized for a discharged tenant and lacked written procedures for alarm systems affecting tenants with cognitive impairment.
Violations (2)
481-69.26(4)a Service Plans: The program failed to ensure service plans were individualized and did not list preferences, interventions, or individualized instructions for one discharged tenant. The service plan's interventions column was incomplete despite required assistance needs.
481-69.32(4)a Life Safety - Emergency Policies / Structure: The program failed to develop written procedures regarding alarm systems for tenants with cognitive impairment. The existing Elopement Policy did not address alarm systems or have a separate written policy for them.
Inspection Report — Jan 24, 2024
Renewal
Date: Jan 24, 2024
Visit Reason
The visit was a renewal (recertification) inspection of Rock Creek Senior Living. The investigation also covered Incidents #113298-I and #117415-I.
Complaint Details
Investigation of Incident #113298-I found no insufficiencies. Investigation of Incident #117415-I found a service plan deficiency.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #113298-I. One deficiency was cited during the investigation of Incident #117415-I related to failure to update service plans as needed.
Violations (1)
481-69.26(1) Service Plans: The program failed to update service plans as needed for 1 of 2 tenants reviewed. Tenant #1 was confused about how to re-enter the building after leaving and the service plan was not updated to reflect the need for 15 minute status checks following an incident.
Inspection Report — Dec 8, 2022
Complaint Investigation
Date: Dec 8, 2022
Visit Reason
Investigation of multiple complaints: Complaint 107618-C, 104736-C, 104780-C, 105284-C, 107056-C, and 107432-C.
Complaint Details
Complaints investigated include 107618-C, 104736-C, 104780-C, 105284-C, 107056-C, and 107432-C.
Findings
Regulatory insufficiencies were cited related to tenant care, involuntary transfer notification, service plan development and updates, and staff training. No insufficiencies were cited during the investigation of Complaint 107618-C.
Violations (7)
481-67.3(2) Tenant Rights: The program failed to ensure one tenant received adequate care and treatment as a follow-up call requested by the physician regarding delusions and hallucinations was not made. The program nurse failed to return telephone calls to family members about the physician's request.
481-69.24(1)b Involuntary Transfer from Program: The program failed to immediately notify the office of long-term care ombudsman by certified mail of the intention to involuntarily transfer one tenant. The Executive Director confirmed the notification was not sent.
481-69.26(1) Service Plans: The program failed to develop a service plan at the time of occupancy for one tenant. No service plan could be located for Tenant #2 who became an occupant on 8/1/22.
481-69.26(3) Service Plans: The program failed to update service plans within 30 days of occupancy for two tenants. Tenant #2 had no initial service plan completed within 30 days, and Tenant #1's plan was revised well after 30 days of occupancy.
481-69.29(3) Staffing: The program failed to ensure four contract/agency staff were appropriately trained to meet tenant needs. No training documentation was found for these staff members.
481-69.30(1) Dementia Specific Education for Personnel: The program failed to ensure two new staff received eight hours of dementia-specific training within 30 days of employment. Training documentation lacked time details to verify completion.
481-69.30(3)a Dementia Specific Education for Personnel: The program failed to ensure two long-term staff received eight hours of dementia-specific training annually. Training documentation lacked time details to verify completion.
Inspection Report — Mar 3, 2022
Annual Inspection
Date: Mar 3, 2022
Visit Reason
Annual inspection of Rock Creek Senior Living was conducted including investigation of Complaint #99691-C, Complaint #102667-C, and Incident #102390-I.
Complaint Details
Complaint #99691-C, Complaint #102667-C, Incident #102390-I
Findings
Multiple regulatory insufficiencies were cited including failure to follow incident report policy, inadequate care resulting in elopement of two tenants, failure to evaluate a tenant's significant change in condition, failure to update service plans with signatures, and failure to maintain operational alarm systems on Memory Care Unit exit doors.
Violations (5)
481-67.2(3) Program Policies and Procedures: The program failed to follow its policy by not completing an incident report for Tenant #3 found soaked in urine and dehydrated on 2/09/22.
481-67.3(2) Tenant Rights: The program failed to provide adequate services by not preventing the elopement of Tenant #1 and Tenant #2 on 12/30/21 due to disarmed Memory Care Unit door alarms and insufficient hourly status checks.
481-69.22(3) Evaluation of Tenant: The program failed to evaluate the functional, cognitive, and health status of Tenant #3 after a significant change when the tenant was found dehydrated with a urinary tract infection.
481-69.26(3)a Service Plans: The program failed to ensure updated service plans were signed and dated by all parties for Tenant C-1.
481-69.32(2) Life Safety - Emergency Policies / Structure: The program failed to ensure the Memory Care Unit's alarm system remained operational at all times, contributing to the elopement of Tenant #1 and Tenant #2.
Inspection Report — Feb 23, 2022
Enforcement
Date: Feb 23, 2022
Visit Reason
This citation was issued following an investigation of Incident 102390-I involving two tenants who eloped from the facility. The citation addresses failures in providing adequate and appropriate services and ensuring the Memory Care Unit's alarm system remained operational.
Complaint Details
Incident 102390-I
Findings
The program failed to provide adequate and appropriate services to two tenants who eloped from the facility on 12/30/21. The Memory Care Unit's alarm system was found to be disarmed during the elopement, and staff did not consistently check the alarms as required.
Violations (2)
481-67.3(2) Tenant rights: The program failed to provide adequate and appropriate services to two tenants who eloped from the facility on 12/30/21. Staff did not check alarms before the elopement was reported.
481-69.32(2) Life safety—emergency policies and procedures: The program failed to ensure the Memory Care Unit's alarm system remained operational at all times, as the alarm was accidentally disarmed and staff lacked a policy for required alarm checks.
Report Facts
Fine amount: 2500
Inspection Report — Jun 21, 2021
Enforcement
Date: Jun 21, 2021
Visit Reason
This citation was issued following a survey conducted from June 21, 2021 to July 8, 2021, regarding failure to provide adequate care and respect to Tenant #4 at Rock Creek Senior Living.
Findings
The facility failed to treat Tenant #4 with consideration, respect, and personal dignity, and failed to provide adequate and appropriate services. Multiple incidents of rough transfers without use of a gait belt, ignoring requests for bathroom use and medication needs, and failure to ensure medication administration were documented and confirmed by staff interviews.
Violations (2)
67.3(1) Tenant rights: The program failed to ensure Tenant #4 was treated with consideration, respect, and personal dignity. Staff were observed roughly transferring Tenant #4 multiple times without using a gait belt and ignoring her requests and needs.
67.3(2) Tenant rights: The program failed to provide adequate and appropriate care to Tenant #4, including failure to assist with transfers properly, failure to observe medication administration, and denial of PRN medications despite availability.
Report Facts
Fine amount: 3000
Inspection Report — Jun 21, 2021
Renewal
Date: Jun 21, 2021
Visit Reason
The visit was a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia and included investigation of Complaint #96989-C.
Complaint Details
Complaint #96989-C was investigated during the visit.
Findings
Several regulatory insufficiencies were cited related to tenant rights, adequate care and services, staffing, dependent adult abuse training, tenant evaluations, service plans, food service, and dementia-specific education for personnel.
Violations (12)
481-67.3(1) Tenant Rights: The program failed to treat Tenant #4 with consideration, respect, and personal dignity as evidenced by multiple incidents of rough transfers, ignoring requests for bathroom use, and failure to ensure medication swallowing.
481-67.3(2) Tenant Rights: The program failed to provide adequate and appropriate care and services to Tenant #4, including failure to use gait belts during transfers and failure to address pain and safety needs.
481-67.9(4)(a) Staffing: The program's registered nurse failed to document competency reviews for 3 of 4 staff within 60 days of hire as required.
481-67.9(6) Staffing: The program failed to provide dependent adult abuse training to 5 of 8 staff as required by Iowa Code section 235B.16.
481-69.22(2) Evaluation of Tenant: The program failed to evaluate the functional, cognitive, and health status of 2 of 3 tenants within 30 days of occupancy.
481-69.22(3) Evaluation of Tenant: The program failed to conduct cognitive evaluations for significant change for 1 of 3 tenants and failed to complete evaluations when significant changes occurred.
481-69.26(1) Service Plans: The program failed to develop service plans based on required evaluations and failed to include specified service needs for 3 current and 1 former tenant.
481-69.26(4)(d) Service Plans: The program failed to include a list of person-centered planned and spontaneous activities for 2 of 3 tenants unable to plan their own activities.
481-69.28(5) Food Service: The program failed to provide orientation and annual in-service training on safe food handling for all 8 staff responsible for food preparation and service.
481-69.28(8) Food Service: The program failed to ensure potentially hazardous foods were held at safe temperatures in the memory care unit, affecting all 13 tenants residing there.
481-69.30(1) Dementia Specific Education for Personnel: The program failed to provide 8 hours of dementia-specific education within 30 days of employment for 3 of 8 staff.
481-69.30(5) Dementia Specific Education for Personnel: The program failed to provide hands-on dementia-specific training for 3 of 8 staff and failed to provide annual training thereafter.
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