Clear Creek Care Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
#1 said the one-to-one sitter should never leave the resident alone and should always be within arms reach of the resident. She said it was important for the one-to-one care giver to be very close to the resident in order to be able to react quickly and prevent falls or injuries. She said the residents' care plan had information regarding fall interventions. CNA #4 was interviewed on 10/20/25 at 3:35 p.m. She said she had taken over for evening shift as the one-to-one care giver for Resident #10 today. She said as the one-to-one care giver it was her responsibility 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 director of nursing (DON), the NHA and the regional nursing consultant were interviewed together on 10/20/25 at 4:26 p.m. The DON said Resident #10 was admitted to the facility on [DATE REDACTED] due to his multiple falls at home. She said residents were assessed for their fall risk upon admission, quarterly and as changes dictate. She said resident care was resident specific to the resident behavior. She said it was important to ensure Resident #10 was monitored consistently because he could not be trusted to be left alone. She said Resident #10 had poor safety awareness and would fall and injure himself if left alone. She said the one-to-one caregiver started after Resident #10 had seven falls within the first six days of admission.The DON said the one-to-one caregiver for Resident#10 was initiated as a fall intervention on 8/30/25 after the resident had a fall with a minor head injury. She said the resident sustained another fall on 9/3/25. She said
she believed the nursing staff was not watching the resident close enough. She said the fall intervention was changed from one-to-one observation, to one-to-one arm's length. She said the on-to-one arm's length was put in place to be more specific for the staff to understand the need to be close to the resident. She said this intervention was added to the resident's care plan for the nurses and on the Kardex (staff directive tool) for the CNAs. The DON said the facility did not provide any specific training for one-to-one caregivers, but the expectation was for the one-to-one caregiver to visually monitor the resident to prevent any falls or injuries. The DON said CNA #1 should always be able to see the resident and should not turn her back on
the resident. The DON said she would talk to CNA #1 regarding the lack of monitoring of Resident #10. The NHA said it was very concerning to find out that the one-to-one caregiver assigned to Resident #10 left him unattended. She said the resident had a history of falls and if the caregiver left the resident unattended, he could sustain another fall with injury. The NHA said CNA #1 should know the potential risk of leaving him alone. The NHA said it was not a good idea for CNA #1 to turn her back on the resident while she was documenting at the nurses' station. the NHA said CNA #1 could have brought the resident behind the nurses' station with her while she did her documentation. The regional nurse consultant said she would initiate training for all nursing staff to start immediately regarding the requirements and importance of one-to-one care givers responsibilities. She said she would include the importance of being within arm's length of the resident while being a one-to-one caregiver.
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CLEAR CREEK CARE CENTER in WESTMINSTER, CO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WESTMINSTER, CO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CLEAR CREEK CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.