Deficiency Records for Clear Creek Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Clear Creek Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have an externally vented heating system. | Fire Safety | 2023-12-14 | 2024-03-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-12-14 | 2024-01-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-11-17 | 2023-12-27 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-11-17 | 2023-12-27 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-11-17 | 2023-12-27 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-11-17 | 2023-12-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-17 | 2023-12-27 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-17 | 2023-12-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-17 | 2023-12-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-17 | 2023-12-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-17 | 2023-12-27 | N |
| 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. | Health | 2023-11-17 | 2023-12-27 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-11-17 | 2023-12-27 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2023-11-17 | 2023-12-27 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-11-17 | 2023-12-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-17 | 2023-12-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-17 | 2023-12-27 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-11-17 | 2023-12-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-17 | 2023-12-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-11 | 2023-09-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-11 | 2023-09-20 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-08-11 | 2023-09-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-13 | 2023-09-20 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-07-13 | 2023-09-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-13 | 2023-09-20 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-29 | 2022-08-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-29 | 2022-08-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-29 | 2022-08-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-26 | 2022-07-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-26 | 2022-07-01 | N |
| 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. | Health | 2022-05-26 | 2022-07-01 | N |
| 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. | Health | 2022-05-26 | 2022-07-01 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-05-26 | 2022-07-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-26 | 2022-07-01 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-05-26 | 2022-07-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-26 | 2022-07-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-26 | 2022-07-01 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-05-26 | 2022-06-15 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-02-11 | 2020-10-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-11 | 2020-10-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-11 | 2020-10-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-01-24 | 2020-02-21 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-01-24 | 2020-02-21 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-24 | 2020-02-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-01-24 | 2020-02-21 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2020-01-24 | 2020-02-21 | N |
| Provide activities to meet all resident's needs. | Health | 2020-01-24 | 2020-02-21 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-01-24 | 2020-02-21 | N |
| 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. | Health | 2020-01-24 | 2020-02-21 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2020-01-24 | 2020-02-21 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2020-01-24 | 2020-02-21 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2020-01-24 | 2020-02-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-01-24 | 2020-02-21 | N |
