Clear Creek Care Center: Accident Hazard Harm - CO
The aide, identified as CNA #1, was specifically assigned one-to-one care for Resident #10, meaning she should never leave him unattended and must remain within arm's reach at all times. Federal inspectors found her violating these requirements on October 20.
Resident #10 was admitted to Clear Creek Care Center after multiple falls at home. Within six days of his arrival, he fell seven times. After a fall on August 30 that caused a minor head injury, administrators implemented one-to-one observation. When he fell again on September 3, they upgraded the requirement to "one-to-one arm's length" supervision.
The director of nursing told inspectors the resident "could not be trusted to be left alone" and had "poor safety awareness." She said he would "fall and injure himself if left alone."
Despite these clear directives, CNA #1 left her assigned resident to document at the nurses' station with her back turned to him. The nursing administrator called this "very concerning," noting that leaving the resident unattended could result in "another fall with injury."
The director of nursing said CNA #1 "should always be able to see the resident and should not turn her back on the resident." The administrator suggested the aide "could have brought the resident behind the nurses' station with her while she did her documentation."
CNA #4, who took over evening shift supervision for the same resident, understood her responsibilities clearly. She told inspectors her job was to "monitor the resident at all times and assist him with transfers and toileting hygiene." She said she "should never leave the resident unattended as the one-to-one care giver."
The facility's own nursing supervisor, interviewed the same day, emphasized that one-to-one sitters "should never leave the resident alone and should always be within arms reach." She explained the caregiver needed to stay "very close to the resident in order to be able to react quickly and prevent falls or injuries."
Clear Creek's administrators acknowledged they provided no specific training for one-to-one caregivers. The director of nursing said the expectation was simply for the assigned aide to "visually monitor the resident to prevent any falls or injuries."
The nursing administrator said CNA #1 "should know the potential risk of leaving him alone," given the resident's documented fall history. The director of nursing promised to "talk to CNA #1 regarding the lack of monitoring of Resident #10."
A regional nursing consultant interviewed with facility leadership said she would "initiate training for all nursing staff to start immediately regarding the requirements and importance of one-to-one care givers responsibilities." The training would emphasize "the importance of being within arm's length of the resident while being a one-to-one caregiver."
The violation occurred despite the resident's care plan containing specific fall interventions and detailed instructions on the Kardex, the staff directive tool used by nursing assistants. Administrators had upgraded his supervision requirements twice in response to continued falls, yet the assigned aide still abandoned her post.
The director of nursing told inspectors she believed previous falls happened because "the nursing staff was not watching the resident close enough." The September 3 fall prompted the facility to specify "arm's length" supervision to make the requirements "more specific for the staff to understand the need to be close to the resident."
Federal inspectors determined the violation caused actual harm to few residents and cited the facility for failing to ensure residents received adequate supervision and assistance devices to prevent accidents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clear Creek Care Center from 2025-10-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
CLEAR CREEK CARE CENTER in WESTMINSTER, CO was cited for violations during a health inspection on October 20, 2025.
Federal inspectors found her violating these requirements on October 20.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.