Rock Creek Alzheimer's Special Care Center.

“Based on record review, documentation review, and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of one resident. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1’s medical record revealed the following:   An incident report for October 26, 2025, documented an unwitnessed fall that required emergency medical services. However, there was no documentation available to review of any action taken to prevent the incident from occurring in the future.  2. In an interview, E2 reported to still be working on the prevention statement. E1 and E2 acknowledged there was no documentation available to review to include the action taken to prevent the incident in the future.”

“Based on documentation review and interview, the manager failed to immediately report suspected abuse according to A.R.S. \'a7 46-454. Findings include: 1. A.R.S. \'a7 46-454(A) stated "...other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit ... All of the above reports shall be made immediately by telephone or online." 2. A.R.S. \'a7 46-454(B) stated "If an individual prescribed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law..." 3. R9-10-101.110 stated "Immediate" means without delay. 4. E1 provided documentation on a reportable event for R1. The documentation revealed notes dated June 27, 2024 at approximately 8:30 AM, R1 struck R2 in the face. E1's notes documented APS was notified on June 28th, 2024 at 3:38 PM. 5. E1 provided documentation on a reportable event for R3. The documentation revealed notes dated July 3, 2024 at approximately 1:00 AM, R3 was found standing over R4 hitting R4 with a shoe. R4 suffered with a laceration to the left eye and bruise to the left ear lobe. E1's notes documented APS was notified on July 5, 2024 at 12:38 PM. 6. In an interview, E1 acknowledged documentation was not available that showed the incidents on R1 and R3 were reported immediately according to A.R.S. \'a7 46-454.”

“Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of four residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R3's medical record revealed a current written service plan dated April 2024. This service plan indicated R3 received medication administration. 2. Review of R3's medical record revealed a signed medication order dated April 2024. This medication order stated "Hydralazine 10 mg take one tablet daily hold for SBP [systolic blood pressure]”

“Based on documentation review and interview, the manager of an assisted living facility authorized to provide directed care services failed to implement policies and procedures to ensure the safety of a resident who may wander. Findings include: 1. A review of Department documentation revealed AL10578 was authorized to provide directed care services. 2. A review of facility documentation revealed an incident report dated October 20, 2023. The incident report stated "[R1] was seen by assigned caregiver at 6:00 am and reportedly walking the community and interacting with other residents... [R1] was seen again at 7:00 am by assigned caregiver. [R1] interacted with charge nurse at 7:15 am - 7:30 am when asked for water...bottle was filled and [R1] appeared to have walked back to [R1's] room. At approximately 8:00 am, the team at our sister community came to the door with [R1]. No injuries or distress noted." 3. A review of the facility's policies and procedures revealed a policy titled "Head Count/Elopement Prevention and Response" dated January 2023. The policy stated "Head count checks are done at least once every hour...documentation on the head count sheet is done minimally at least once an hour...Immediate notification to the charge nurse and all staff via walkie talkie if any resident is not accounted for...proceed with search and notification to appropriate disciplines...staff must ensure area is properly assessed to verify no resident has gone outside...checking the outside perimeters and gates to ensure resident has not proceeded out of the secured area." 4. A review of personnel files contained "employee disciplinary record" that revealed "hourly check process was not followed per policy". 5. In an interview, E1 acknowledged policies and procedures were not implemented that ensure the safety of a resident who may wander.”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of four residents sampled. Findings include: 1. A review of R4's medical record revealed an order for wound care (dated May 26, 2023). 2. A review of R4's medical record revealed a service plan for directed care services (dated in April 4, 2023). However, the service plan did not include wound care services were being provided. 3. R4's file contained documentation from the wound clinic for: -a pressure ulcer on the coccyx area; -a ulcer on the left heel; and -a ulcer on the right foot. 4. In an interview, E1 acknowledged the service plan was not updated within 14 calendar days after a significant change in condition.”

“Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of assisted living services provided to the resident, for one of four residents sampled. Findings include: 1. A review of R3's medical record revealed a service plan for directed care services. The service plan stated R3 was to receive assistance with "bathing, dressing, toileting". However, documentation that these services were provided was not available for November and December 2022. 2. In an interview, E2 reported not being able to locate the ADL sheets. E2 revealed the assisted living services were provided to R3, however, the caregiver who provided the service had not documented the service.”

“Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse stating whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for two of four residents reviewed accepted by the assisted living facility on or after October 1, 2013. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R1's medical record revealed no documentation stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R1's acceptance date, this documentation was required. 2. In an interview, E1 acknowledged documentation was not available showing R1 provided documentation signed by a medical practitioner or a registered nurse stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints.”

“Based on record review and interview, the manager failed to ensure a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for three of four directed care residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident, and the Department was unable to determine substantial compliance. Findings include: 1. A review of R1's medical record revealed a service plan for directed care services dated in May 2023. However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 2. A review of R2's medical record revealed a service plan for directed care services dated in July 2023. However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 3. A review of R4's medical record revealed a service plan for directed care services dated in April 2023. However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 4. In an interview, E1 reported an assessment form and a flowsheet are used to create the service plan. E1 and E2 acknowledged R1, R2, and R4's service plans did not include documentation of skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.”

“Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or from a medical practitioner stating weighing the resident was contraindicated, for two of four residents sampled who received directed care services. Findings include: 1. A review of R1's medical record revealed a current service plan dated in May 2023 for directed care services. However, the service plan did not include documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated. 2. A review of R2's medical record revealed a current service plan dated in July 2023 for directed care services. However, the service plan did not include documentation of R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated. 3. In an interview, E1 reported vital sheets are used to collect this information. E1 and E2 acknowledged R1 and R2's service plans did not include the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated.”