Clear Creek Nursing & Rehabilitation Center

Inspectors wroteBased on observations and staff interviews, the facility failed to store, label and date food in 1 of 1 freezer and 1 of 1 walk-in cooler and failed to remove produce with signs of spoilage in the walk-in cooler. These practices had the potential to affect food served to residents. Findings Include:a. During an initial kitchen tour of the walk-in cooler, conducted with the Dietary Manager on 05/11/2026 at 10:25 AM, the following concerns were identified:- Two packages of strawberries were stored in their original packaging. Four strawberries in one package were observed covered with a white, fuzzy substance. The second package contained one visibly spoiled strawberry.- One pack of blueberries was stored in its original packaging. Five blueberries were observed covered with a white, fuzzy substance. [...]

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to change the pressure ulcer dressing as ordered for 1 of 3 residents reviewed for pressure ulcers (Resident #11).

Inspectors wroteBased on observation and staff interviews, the facility failed to label an in-use insulin pen with the opened and expiration date information for 1 of 4 medication carts (200-hall medication cart).

Inspectors wroteBased on observations, record review, and resident, staff, Dietary Manager, and Registered Dietitian (RD) interviews, the facility failed to provide food that accommodated a documented allergy to pineapple for 1 of 4 residents reviewed for nutrition (Resident #61).

Inspectors wroteBased on record review and interviews with staff, the facility failed to ensure the medical record was complete regarding documentation of wound care for 1 of 3 residents reviewed for pressure ulcers (Resident # 11).

Inspectors wroteBased on record review, and staff and resident interviews, the facility failed to provide resolution of Resident Council Meeting grievances for 4 of 6 monthly Resident Council Meetings. The Resident Council had concerns during resident council meetings that revealed no follow up resolutions (09/19/24, 11/14/24, 12/11/24, and 01/16/24.)

Inspectors wroteBased on record reviews and staff interviews, the facility failed to maintain psychiatric progress notes in the electronic medical record (Residents #21, # 31, #37 and #90), and to accurately document the completion of an order on the medication administration record (Resident #36). This deficient practice occurred for 5 of 5 residents (Resident #21, # 31, #36, #37 and #90) reviewed for accurate medical records.

Inspectors wrote3. According to the facility's infection control policy subsection titled Enhanced Barrier Precautions dated 4/03 and revised 6/13/24, personal protective equipment (PPE) including a gown and gloves was to be worn during high contact care for a resident with an indwelling medical device such as a feeding tube. On 3/19/25 at 10:06 AM Nurse #1 donned a gown and gloves at the doorway of Resident #100's room due to the resident being on enhanced barrier precautions. Nurse #1 was observed as she provided a dressing change of the (PEG) percutaneous endoscopic gastrostomy tube (a thin, flexible tube inserted through the skin and into the stomach) insertion site. After cleansing the insertion site and applying a clean dressing, Nurse #1 removed her gloves and took a pen out of her pocket. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II referral was made after a resident was given new mental health diagnoses for 1 of 3 residents (Resident #71) reviewed for PASRR.

Inspectors wroteBased on observations, record review, and staff and Nurse Practitioner interviews, the facility failed to remove an indwelling urinary catheter per the physician's order and failed to keep a urinary catheter drainage bag and tubing from touching the floor to reduce the risk of infection for 1 of 4 residents reviewed for urinary catheters (Resident #36).

Inspectors wroteBased on observations, record review, and family member and staff interviews, the facility failed to obtain a physician order for oxygen therapy for 1 of 1 resident reviewed for respiratory care (Resident #72).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a performance review every 12 months for 2 of 5 Nurse Aides (NAs) reviewed to ensure in-service education was designed to address the outcome of the performance evaluations (NA #2 and NA #3).

Inspectors wroteBased on record review, resident/ family and staff interviews, the facility failed to protect a resident's right to be free from verbal and mental abuse when Nurse Aide #4 and Social Worker confronted Resident #2 in her room and intimidated her into not submitting a grievance. Nurse Aide #4 refused to provide incontinent care for Resident #2 by taking her to her room and yelling at her by stating she could poop in her diaper like everyone else does then slammed the door as she left. Nurse Aide #4 yelled at Resident #2 who requested incontinent care, by stating I am not your CNA and will never be your CNA no more in life. These actions caused Resident #2 to feel intimidated, devalued, deprived of care, ignored, depressed, without control of her life, trapped, upset, and as if she did something wrong. This occurred for 1 of 1 resident reviewed for abuse.

Inspectors wroteBased on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey completed on 05/26/22, the complaint investigation survey completed on 7/13/23, and the complaint investigation survey completed on 08/11/23. This was for five repeat deficiencies originally cited in the areas of freedom from abuse and neglect, develop/implement abuse policies, activities of daily living provided for dependent residents, development of comprehensive care plans, infection prevention and control that was subsequently recited on the current recertification and complaint investigation survey of 11/17/23. [...]

Inspectors wroteBased on staff interviews and record reviews the facility failed to implement an infection surveillance plan for monitoring and tracking infections in the facility. This practice had the potential to affect 84 of 84 residents in the facility.

Inspectors wroteBased on staff interviews, the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection and Control Program. This had the potential to affect 84 of the 84 residents at the facility.

Inspectors wrote3. Resident #25 was admitted to the facility on [DATE] with diagnoses inclusive of heart failure, stage 2 chronic kidney disease, pulmonary hypertension and peripheral vascular disease. The quarterly MDS assessment dated [DATE] indicated Resident #25 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, personal hygiene, and toileting. He was independent with eating and was totally dependent on bathing. A review of Resident #25's medical record indicated there was no assessment or physician's order for self-administration of medications. A review of Resident #25's Medication Record for November 2023 revealed an active physician's order for ammonium lactate lotion and natural tears eye ointment. The Medication Record did not reveal an order for the following over-the-counter medications: [...]

Inspectors wroteBased on observations, interviews with residents (Residents #23, #27, #36, #38, #47, #50, #58, #74, and #140) and staff and record review, the facility failed to provide privacy for 5 months during Resident Council meetings.

Inspectors wroteBased on observations, interviews with residents and staff and record review, the facility failed to provide supplemental oxygen (O2) per physician (MD) order for 2 of 2 sampled residents reviewed for respiratory care (Residents #69 and #14).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to discard expired medications and date opened insulin vials and eye drops in 1 of 2 medication rooms (300 hall/400 hall medication room) and 3 of 5 medication carts (300 hall/400 hall medication cart, 600 hall medication cart and 500 hall medication cart).

Inspectors wroteBased on observations, record review and interviews with residents, family and staff, the facility failed to provide adaptive equipment during meals to 2 of 2 sampled residents reviewed for the use of adaptive equipment (Residents #79 and #37).

Inspectors wroteBased on record review and staff interviews, the facility failed to clarify and update the medical records to reflect the desired advance directive for 1 of 7 residents reviewed for code status (Resident #64).

Inspectors wroteBased on record review, grievance review, policy review, resident/family interviews and staff interviews, the facility failed to ensure a grievance investigation was conducted and a written resolution was provided per the facility's grievance policy for 1 of 1 resident (#2) reviewed for grievances.

Inspectors wroteBased on record review and review of the facility's policy entitled Abuse and Neglect , and resident and staff interviews, the facility failed on 2 occasions to implement its own policy to immediately report an incident of abuse or neglect to the Administrator. This affected 1 of 1 resident reviewed for abuse (Resident #2).

Inspectors wroteBased on observations, resident interviews, staff interviews, and record review the facility failed to develop an individualized person-centered comprehensive care plan in the area of visual impairment (Resident #14). This deficient practice was for 1 of 1 resident whose comprehensive care plans were reviewed.

Inspectors wroteBased on record review, observations, and interviews with the resident, staff and the Hospice Nurse, the facility failed to provide a dependent resident with nail care and facial hair trim to 1 of 4 residents (Resident #68) reviewed for assistance with activities of daily living.

Inspectors wroteBased on record review, observations, and family and staff interviews, the facility failed to provide supervision for meals for 1 of 1 resident reviewed for quality of care (Resident #29).

Inspectors wroteBased on observations, a resident interview, staff interviews and record review, the facility failed to honor a resident's food preferences for no sandwiches and no fish. This failure occurred for 1 of 4 residents reviewed for food preferences (Resident #37).

Inspectors wroteBased on observations, interviews with residents and staff, and record review, the facility failed to provide beverages per resident choice to 3 of 3 sampled residents reviewed for receiving their preferred beverages (Residents #37, #22, and #79).