Clear Creek Care Center
CLEAR CREEK CARE CENTER in WESTMINSTER, CO — inspection on October 20, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
#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] 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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