Clear Creek Care Center

Smoke Deficiencies

Provide properly protected cooking facilities.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

Nutrition and Dietary Deficiencies

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

A complaint survey, prompted by #CO38814 was conducted on 1/21/25. One deficiency was cited. Based 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. Findings include:I. Facility policy and procedureThe Bathing/Shower policy, revised February 2018, was provided by the regional clinical resource (RCR) on 1/21/25 at 4:24 p.m. It read in pertinent part, "The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident' s skin. "The documentation includes the date and time the shower/bath was performed, the name and title of the individual who assisted the resident with the shower, all the assessment data obtained during the shower, how the resident tolerated the shower, if the resident refused the shower, the reason why, the intervention taken and report the refusal to the supervisor."The Activity of Daily Living policy, revised March 2018, was provided by the RCR on 1/21/25 at 4:20 p.m. It read in pertinent part, "Residents who are unable to carry out activities of daily living (ADL) independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene and oral hygiene. "Care and services will be provided for the following activities:-Bathing, dressing, grooming and oral care;-Transfer and ambulation;-Toileting;-Dining to include meals and snacks; and-Using speech, language or other functional communication systems."II. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on 9/4/23. According to the January 2025 CPO, diagnoses included end stage renal failure, dependence on dialysis, cognitive communication deficit, limitations of activities due to disability, sacral pressure injury and depression. The 12/30/24..

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 7.1.6.2. This was evidenced by the following:Entrance north ramp has gaps in the concreteNFPA 101 7.1.6.2 Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 in. (6.3 mm). Changes in elevation exceeding 1/4 in. (6.3 mm), but not exceeding 1/2 in. (13 mm), shall be beveled with a slope of 1 in 2. Changes in elevation exceeding 1/2 in. (13 mm) shall be considered a change in level and shall be subject to the requirements of 7.1.7This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director at the exit conference. Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:1.Penetration needs fire caulk south nurse station.2.Medicine room needs fire caulk by south nurse stationNFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director at the exit conference. Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99 and 55. This was evidenced by the following:Oxygen Transfill rooms need a vent 12" of the floorNFPA 556.15.7 Inlets to the Exhaust System.6.15.7.1 The exhaust ventilation system design shall take into account the density of the potential gases released.6.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor.6.15.7.3 For gases that are lighter than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the ceiling.These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on April 11, 2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies." This structure is a one (1) story, Type V (000) (VB) construction. The facility has a partial basement that is used for support services only and there is no resident access. The facility is licensed for 80 beds and the census on the date of the survey was 62.The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. The facility is classified as fully sprinklered. The results of this survey was discussed with the Maintenance Director and the Facility Administrator during the exit conference.