Clear Creek Care Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#10) of four residents reviewed for accidents out of seven sample residents. Resident #10 was admitted on [DATE] for long term care with a diagnosis of dementia. According to the care plan, Resident #10 was determined to be a high fall risk. On 8/30/25 Resident #10 sustained an unwitnessed fall. The facility updated the resident's care plan to indicate he needed a one-to-one caregiver. However, on 9/3/25 Resident #10 sustained an unwitnessed fall when he was found on the floor in his room with a laceration to his head. Resident #10 was transported to the hospital for further evaluation. Resident #10 sustained a three to four millimeter left tentorial subdural hematoma (brain bleed) and posterior left tenth and eleventh rib fractures. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#2 and #1) of three residents reviewed for bathing out of three sample residents. Specifically, the facility failed to ensure Resident #2 and Resident #1, who were dependent on staff for bathing, received their scheduled showers.

Inspectors wroteBased on observations and interviews, the facility failed to ensure facility menus met the needs of residents and were followed. Specifically, the facility failed to: -Ensure menu extensions were followed; and, -Ensure residents were provided with all menu options and substitutions were offered when appropriate.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in a sanitary manner. Specifically, the facility failed to: -Ensure kitchen staff prepared and served food in a sanitary environment in the main kitchen; and, -Ensure the two facility ice machines were properly cleaned and sanitized according to the manufacturer's instructions.

Inspectors wroteBased on record review and interviews the facility failed to ensure residents were kept free from unnecessary medications for four (#15, #16, #33 and #76) of five residents reviewed for unnecessary medications out of 47 sample residents. Specifically, the facility failed to ensure informed consents were signed prior to the administration of psychotropic medications for Residents #15, #16, #33 and #76.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with professional standards on two of four medication carts. Specifically, the facility failed to ensure: -Medications were labeled with the date opened; -Expired and discontinued medications were removed from the medication cart; and, -Labeled medications were legible.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on two of three units. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate infection control practices; -Ensure high touch areas were cleaned; -Ensure staff followed proper hand hygiene practices; -Ensure hand hygiene was offered to residents prior to meals; and, -Ensure Foley catheter bags were hung in a sanitary manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide written notification of room changes and roommate changes for two (#72 and #14) of four residents reviewed for notifications out of 47 sample residents. Specifically, the facility failed to provide timely written and/or verbal notification of room and/or roommate changes to Resident #72 and Resident #14 and/or their representatives.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#29) of two residents reviewed for abuse out of 47 sample residents was kept free from abuse. Specifically, the facility failed to ensure Resident #29 was kept free from physical abuse by Resident #27.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) for two (#17 and #19) of two residents reviewed for ADLs out of 47 sample residents. Specifically, the facility failed to ensure Resident #17 and #19 received showers as scheduled.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure residents with limited range of motion (ROM) received the appropriate treatment and services to maintain or prevent a further decrease in their ROM for one (#36) of one resident reviewed for limited ROM out of 47 sample residents. Specifically, the facility failed to ensure Resident #36 was provided with restorative services to maintain or prevent worsening of her right hand contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#54) of one resident out of 47 sample residents. Specifically, the facility failed to ensure trauma assessments were conducted to determine the residents history of post-traumatic stress disorder (PTSD) and/or trauma, identify triggers and develop person centered interventions within the comprehensive care plan for Resident #54.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received food prepared in a form designed to meet their needs for two (#15 and #39) of four residents reviewed for therapeutic diets out of 47 sample residents. Specifically, the facility failed to provide meals prepared according to the prescribed food orders for Resident #15 and Resident #39.

Inspectors wroteBased on record review and interviews, the facility failed to ensure five out of five nursing staff members were able to demonstrate skills and techniques necessary to care for residents' needs. Specifically, the facility failed to conduct annual nursing competencies. I. Facility policy and procedure The Competency of Nursing Staff policy, revised May 2019, was provided by the infection preventionist (IP) on 12/1/22 at 3:11 p.m. It documented in pertinent part, All nursing staff must meet the specific competency requirements of their respective licensure and certification. In addition, nurse assistants will participate in a facility-specific competencies-based staff development and training program, and demonstrate specific competencies and skill sets deemed necessary to care for the needs of the residents as identified through resident assessments and described in the plans of care. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in two of four medication carts and one of two storage rooms. Specifically the facility failed to: -Ensure loose medications in cart were properly disposed of; -Ensure temperature of refrigerators were kept within a safe range; and, -Ensure medications were labeled with open dates.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance improvement program (QAPI) to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to resident rights, quality of care, pharmacy services, and infection control. The facility failed to identify quality deficiencies and develop effective action plans to ensure systemic and lasting change and improvements in these areas. Specifically, the QAPI committee failed to identify and address concerns related to resident rights, quality of care, pharmacy services and infection control.

Inspectors wroteBased on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment in two of two units. Specifically the facility failed to: -Ensure proper hand hygiene during peri-care (providing care to private areas); -Ensure scissors were clean/sanitized before and and after wound care; -Ensure clean supplies were not stored in the soiled utility rooms; and, -Ensure high touch areas were cleaned in resident rooms.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the residents' right to make choices about aspects of their lives in the facility that were significant to them for one (#32) of 17 residents reviewed for bathing preferences out of 22 sample residents. Specifically, the facility failed to provide consistent showers for Residents #32 according to their preferences and routine shower schedules.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure two (#26 and #52) residents out of three who required respiratory care received the care consistent with professional standards of practice out of 22 sample residents. Specifically, the facility failed to : -Ensure physicians orders documented the appropriate care of a continuous positive airway pressure (CPAP) machine for Resident #26; -Follow manufacturer recommendations to maintain, clean, sanitize, and store Resident #26's CPAP; -Accurately complete section O in Resident #26's comprehensive minimum data set (MDS) assessment under respiratory treatments; -Ensure a care plan was in place to include settings, cleaning, disinfecting, and storage of Resident #26's CPAP; and, -Clean and store Resident #52's nebulizer appropriately.

Inspectors wroteBased on resident, staff interviews and record review, the facility failed to ensure a dignified existence was provided for one (#40) of three residents reviewed out of 37 sample residents. Specifically, the facility failed to respond in a timely manner to Resident #40's requests for assistance after incontinence episodes and did not honor her request for a specific agency staff member to not work with her. Due to the agency staff member not providing timely incontinence care on one occasion in June 2021, the resident reported she felt embarrassed, that her health was being jeopardized and that her blood pressure increased. After the resident requested that agency staff member not work with her again, the agency staff member did work with the resident in July 2021. The resident requested to be changed by the agency staff member in July 2021 due to her skin becoming irritated. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in two of two units. Specifically, the facility failed to: -Ensure staff wore masks appropriately while in areas of the facility with potential residents; -Ensure residents were offered hand hygiene before meals; and, -Ensure wound care was provided in a sanitary manner for Resident #54.

Inspectors wroteBased on observations, interviews, and record review; the facility failed to honor resident choices for three (#9, #10, and #57) out of eight resident's reviewed for self-determination. Specifically, the facility failed to: -Ensure Residents #9, and #10 received showers according to their choice of frequency; -Ensure Resident #9 received a minimal standard of nail care according to the resident's choice; and -Honor Resident #57 choice to stay in bed.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for five (#27, #40, #41, #42, and #55) of six residents reviewed for respiratory care out of 37 total sample residents. Specifically, the facility failed to: -Ensure oxygen tubing was marked with the date the tubing was replaced for Resident #27 and #41; -Obtain physician orders for oxygen that includes liter flow, frequency, and route for Resident #40 and #42; -Ensure oxygen was included on the comprehensive care plan for Resident #40; and, -Ensure CPAP machine was cleaned for Resident #27 and #55.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide services by sufficient numbers of personnel on a 24 hour basis to provide nursing care to all residents in accordance with resident care plans on one of two halls reviewed for sufficient nursing staff. Specifically, the facility failed to provide sufficient certified nurse aide (CNA) staff to ensure Residents #10, #18, and #40, on Alpine Meadows, and Residents #14, #51, #54, #55 and #159 on Challenger Pointe had their call lights answered timely and showers were provided per resident preference and as scheduled for Residents #9, #10, #14, #54, and #159.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure all drugs and biologicals were properly labeled, dated, stored/removed in one of two medication storage rooms and two of four medication carts. Specifically, the facility failed to ensure expired vaccines were removed timely and beverages were not kept in the same refrigerator for one of two medication storage room refrigerators as well as ensuring expired ear drops, throat spray, loose tablets, suppositories, and injectable medications were labeled and stored properly in two of four medication carts.

Inspectors wroteBased on record review and interviews, the facility failed to prevent misappropriation of property for two (#6 and #15) of 12 residents reviewed for missing property, out of 37 sample residents. Specifically, the facility failed to: -Ensure Resident #6's new lock box was secured after her previous lock box with money went missing; and, -Prevent an agency staff member from taking rings from Resident #15.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide care and services to prevent the development and worsening of pressure injuries for two (#15 and #54) of four residents reviewed out of 37 sample residents. Specifically, the facility failed to: -Notify the physician of a new toe wound, developed from a brace, to obtain treatment orders for Resident #54; and, -Prevent the development of a pressure wound to Residents #15's back when her air mattress deflated, and she was lying on her oxygen tubing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to: -Ensure the storage of food in the nourishment/snack freezers was not stored with ice packs for residents in three out of four freezers; and, -Ensure all food items are labeled with date opened and resident name if a resident specific food item, and discard any opened, unlabeled, undated food items.