Clear Creek Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Clear Creek Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF690Aug 11, 2023

  Based on record reviews, staff, Responsible Party text communication (RP), Nurse Practitioner (NP), physician (MD), and Urology Physician Assistant (PA) interviews, the facility failed to implement the Urology Physician's orders dated 6/9/23 for prophylactic antibiotic treatment for recurrent urinary tract infections (UTI) and to discontinue a medication to treat an overactive bladder. The facility also failed to ensure staff were trained on the correct procedure to collect a urine specimen and ensure the laboratory was notified there was a specimen for pick up. The deficient practice affected 1 of 3 residents reviewed for urinary tract infections (Resident #1). […]

• Actual harm, isolatedF600Nov 17, 2023

  Based on record review, resident/ family and staff interviews, the facility failed to protect a resident's right to be free from verbal and mental abuse when Nurse Aide #4 and Social Worker confronted Resident #2 in her room and intimidated her into not submitting a grievance. Nurse Aide #4 refused to provide incontinent care for Resident #2 by taking her to her room and yelling at her by stating she could poop in her diaper like everyone else does then slammed the door as she left. Nurse Aide #4 yelled at Resident #2 who requested incontinent care, by stating I am not your CNA and will never be your CNA no more in life. […]

• Actual harm, isolatedF600Aug 11, 2023

  Based on record review, resident, Family member, and staff interview, the facility failed to protect a resident right to be free from employee to resident verbal abuse for 1 of 2 residents investigated for abuse (Resident #2). Resident #2 reported needing assistance with toileting when a Nurse Aide (NA #6) entered her room and NA #6 refused to assist her with incontinence care stating she didn't have time. Resident #2 alleged later that same evening NA #6 returned to her room to place her on the bed pan and verbalized threats while shaking her hand at the resident in a manner which made the resident feel deflated, defeated, tearful, and insignificant. […]

• Actual harm, isolatedF607Aug 11, 2023

  Based on observations, record reviews, staff and resident interviews the facility failed to remove Nurse Aide (NA) #6 from a resident care assignment after NA #6 shook her clinched hands (closed fist) at her and stated, I don't have time to deal with you and if she needed to pee that bad, she should have made her company leave before supper. Resident #2 reported the interaction on the evening of 7/31/23 made her feel deflated, defeated, tearful, insignificant, like I am this big (holding up two fingers close together), and afraid to ask for anything else because she was concerned NA #6 would retaliate against me. NA #6 continued to provide care to other residents in the facility after the incident until the end of her shift at 7:00 pm. […]

• Actual harm, isolatedF550Jul 13, 2023

  Based on record review, observations, resident, and staff interviews, the facility failed to maintain a resident's dignity by not providing incontinence care. Resident #3 stated she felt frustrated and mad. This occurred for 1 of 3 residents reviewed for dignity (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE]. Resident #3's quarterly Minimum Data Set, dated dated dated [DATE] revealed she was cognitively intact with refusal of care occurring 1 to 3 days during the assessment period. She required extensive assistance with bed mobility, transfers, and toilet use. […]