Inspection Reports for Clear Creek Nursing and Rehabilitation Center
10506 Clear Creek Commerce Dr, Mint Hill, NC 28227, NC, 28227
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
156% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 7
Mar 21, 2025
Visit Reason
The inspection was conducted based on complaints and concerns related to unresolved Resident Council grievances, failure to complete PASRR level II referrals, urinary catheter care issues, respiratory care orders, nurse aide performance reviews, medical record maintenance, and infection control practices.
Findings
The facility failed to resolve Resident Council grievances, complete PASRR level II referrals for residents with new mental health diagnoses, timely remove indwelling urinary catheters per physician orders, maintain accurate medical records including psychiatric progress notes, complete nurse aide performance reviews annually, and consistently follow infection prevention and control policies including hand hygiene and use of personal protective equipment during care.
Complaint Details
The visit was complaint-related, triggered by multiple concerns including unresolved Resident Council grievances, failure to complete PASRR referrals, catheter care issues, missing physician orders, incomplete nurse aide performance reviews, missing psychiatric progress notes, and infection control breaches. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide resolution of Resident Council Meeting grievances for 4 of 6 monthly meetings. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure PASRR level II referral was made after new mental health diagnoses for 1 of 3 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to remove indwelling urinary catheter per physician's order and failed to keep catheter drainage bag and tubing from touching the floor for 1 of 4 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain a physician order for oxygen therapy for 1 of 1 resident reviewed for respiratory care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete a performance review every 12 months for 2 of 5 Nurse Aides reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain psychiatric progress notes in the electronic medical record and accurately document completion of an order on the medication administration record for 5 of 5 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to perform hand hygiene during meal service and failed to follow Enhanced Barrier Precautions including PPE use during G-tube feeding and dressing changes for staff observed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident Council Meetings with unresolved grievances: 4
Residents reviewed for PASRR: 3
Residents reviewed for urinary catheters: 4
Nurse Aides reviewed for performance reviews: 5
Residents reviewed for medical records accuracy: 5
Staff observed for infection control practices: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #3 | Entered physician order to remove urinary catheter but was unsure if catheter was removed | |
| Nurse #5 | Resident #36's assigned nurse who removed urinary catheter on 03/17/25 | |
| Nurse #6 | 3rd shift nursing supervisor | Documented catheter removal on MAR but denied removing catheter |
| Activity Director | AD | Reported completing grievances but failed to document resolutions in Resident Council minutes |
| Social Worker | SW | Reported not receiving Resident Council grievances since August 2024 |
| Administrator | Unaware of grievance resolution status and PASRR referrals; expected concerns to be addressed | |
| Nurse Practitioner | NP | Ordered urinary catheter removal and was unaware order was not completed; aware of oxygen use but no order |
| Director of Nursing | DON | Unaware of catheter removal failure; expected infection control compliance; responsible for nurse aide performance reviews |
| Nurse #1 | Failed to perform hand hygiene and PPE use during G-tube dressing change | |
| Nurse #4 | Failed to apply gown during G-tube feeding despite awareness of policy | |
| Nursing Assistant #2 | NA #2 | Failed to perform hand hygiene during meal service |
| Staff Development Coordinator | SDC | Responsible for monitoring nurse aide performance reviews; unaware why reviews were missing |
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 17, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to remove an indwelling urinary catheter per physician's order and failure to keep the urinary catheter drainage bag and tubing from touching the floor, increasing infection risk for Resident #36.
Findings
The facility failed to remove Resident #36's indwelling urinary catheter on the ordered date of 03/15/25, with the catheter still in place on 03/17/25. Additionally, the catheter tubing and drainage bag were observed lying on the floor, which increases infection risk. Interviews with nursing staff revealed confusion and failure to complete the catheter removal order as scheduled.
Complaint Details
The complaint investigation found that Resident #36's catheter removal order dated 03/15/25 was not completed as ordered, and the catheter remained in place until 03/17/25. The catheter tubing and drainage bag were found lying on the floor, contrary to infection control protocols. Interviews with multiple nurses, the Nurse Practitioner, Director of Nursing, and Administrator confirmed the order was not followed and the risk of infection was increased.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to remove an indwelling urinary catheter per physician's order for Resident #36. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to keep urinary catheter drainage bag and tubing from touching the floor, increasing infection risk. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for urinary catheters: 4
Date order to remove catheter: Mar 15, 2025
Date catheter actually removed: Mar 17, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #3 | Nurse | Entered the physician order to remove Resident #36's catheter on 03/15/25 but was not assigned nurse on that date and unsure if catheter was removed. |
| Nurse #5 | Assigned Nurse | Assigned nurse on 03/17/25 who removed Resident #36's catheter at approximately 10:30 AM. |
| Nurse #6 | 3rd Shift Nursing Supervisor | Documented catheter removal on MAR but did not recall seeing order or removing catheter. |
| Nurse Practitioner | Nurse Practitioner | Ordered removal of Resident #36's catheter on 03/15/25 and was unaware the order was not completed. |
| Director of Nursing | Director of Nursing | Confirmed catheter was not removed as ordered and explained wound healing was not a supporting diagnosis for catheter use. |
| Administrator | Administrator | Stated catheter removal orders should be completed on the date ordered and catheter tubing and drainage bags should not lie on the floor. |
| NA #5 | Nurse Aide | 3rd shift NA assigned to Resident #36 on 03/16/25 who emptied and secured drainage bag under bed frame on 03/17/25. |
Inspection Report
Follow-Up
Deficiencies: 1
Nov 17, 2023
Visit Reason
The visit was a follow-up observation and investigation regarding the facility's failure to provide adequate supervision during meals for Resident #29, who was at risk for aspiration due to severe oropharyngeal dysphagia and required one-to-one assistance during feeding.
Findings
The facility failed to provide adequate supervision for meals for Resident #29, despite care plans and physician orders indicating the need for one-to-one assistance and supervision during meals due to aspiration risk. Interviews with family members, nursing staff, and the Speech Therapist confirmed inconsistent supervision and lack of staff awareness of the resident's needs.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide supervision for meals for Resident #29, who required one-to-one assistance due to aspiration risk. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 1
Date of survey completed: Nov 17, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #5 | Nurse | Reviewed care plan and indicated Resident #29 required partial/moderate assistance with eating; observed Resident #29 alone during dinner meals. |
| Nurse Aide #7 | Nurse Aide | Usually assigned to Resident #29; fed herself; ate breakfast in room, lunch in dining room, dinner in room; could not recall meal ticket indicating one-on-one assistance. |
| Nurse Aide #4 | Nurse Aide | Delivered tray and assisted with tray setup; did not supervise meals; unaware of one-to-one supervision requirement. |
| Speech Therapist | Speech Therapist | Supervised Resident #29 during lunch; educated nursing staff on diet recommendations and safe swallow strategies; indicated Resident #29 required supervision during meals. |
| Director of Nursing | Director of Nursing | Reviewed care plan; expected staff to check communication tools and meal tickets; expected Resident #29 to be supervised or transferred to dining area for supervision. |
Inspection Report
Complaint Investigation
Deficiencies: 16
Nov 17, 2023
Visit Reason
The inspection was conducted based on complaint investigations and recertification surveys to assess compliance with federal regulations related to resident care, abuse prevention, infection control, medication management, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to assess residents for medication self-administration, failure to provide privacy during resident council meetings, failure to clarify and update advance directives, failure to conduct and resolve grievances properly, verbal and mental abuse of a resident by staff, failure to report abuse incidents timely, failure to provide comprehensive care plans for visual impairment, failure to provide adequate assistance with activities of daily living, failure to provide supplemental oxygen per physician orders, failure to discard expired medications and date opened medications, failure to honor resident food and beverage preferences, failure to provide adaptive eating equipment, and failure to maintain an effective infection prevention and control program with a qualified infection preventionist.
Complaint Details
The complaint investigation revealed multiple concerns including medication self-administration without assessment, lack of privacy during resident council meetings, conflicting advance directives, failure to investigate grievances, verbal and mental abuse by staff, failure to report abuse incidents timely, inadequate care plans, failure to provide assistance with activities of daily living, failure to provide oxygen per orders, expired medications in use, failure to honor food and beverage preferences, lack of adaptive equipment during meals, and ineffective infection prevention and control program.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Level of Harm - Actual harm: 1
Level of Harm - Potential for minimal harm: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failure to assess residents for medication self-administration and allow residents to self-administer medications safely. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide privacy for resident council meetings. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to clarify and update advance directives leading to conflicting code status orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to conduct grievance investigations and provide written resolutions per policy. | Level of Harm - Minimal harm or potential for actual harm |
| Verbal and mental abuse of a resident by Nurse Aide and Social Worker, including intimidation to prevent grievance filing and refusal of incontinent care. | Level of Harm - Actual harm |
| Failure to immediately report incidents of abuse or neglect to the Administrator as required by policy. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide dependent resident with nail care and facial hair trim. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide supervision during meals for a resident at risk for aspiration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide supplemental oxygen per physician order and failure to properly document oxygen orders on MAR. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to discard expired medications and date opened insulin vials and eye drops in medication rooms and carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to honor resident food preferences for no sandwiches and no fish. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide beverages per resident choice and fluid needs. | Level of Harm - Potential for minimal harm |
| Failure to provide adaptive eating equipment and utensils as recommended by therapy. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an effective Quality Assessment and Assurance program to monitor and sustain corrective actions for repeated deficiencies. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to designate a qualified infection preventionist responsible for the infection prevention and control program. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement an infection surveillance plan for monitoring and tracking infections in the facility. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected by medication self-administration deficiency: 4
Residents attending Resident Council meetings: 9
Residents reviewed for advance directives: 7
Residents reviewed for abuse: 1
Residents reviewed for activities of daily living assistance: 4
Residents reviewed for respiratory care: 2
Medication rooms observed: 2
Medication carts observed: 5
Residents reviewed for food preferences: 4
Residents reviewed for beverage preferences: 3
Residents reviewed for adaptive equipment: 2
Residents affected by infection prevention deficiencies: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #4 | Nurse Aide | Named in verbal and mental abuse findings and refusal to provide incontinent care |
| Social Worker | Social Worker | Named in verbal and mental abuse findings and grievance investigation |
| Nurse #5 | Nurse | Named in medication and abuse findings |
| Nurse #6 | Nurse | Named in medication and oxygen order findings |
| Nurse #2 | Nurse | Named in food, beverage, and oxygen findings |
| Nurse #8 | Nurse | Named in oxygen and food/beverage findings |
| Nurse #10 | Nurse | Named in adaptive equipment and food/beverage findings |
| Nurse Practitioner | Nurse Practitioner | Named in oxygen order findings |
| Director of Nursing | Director of Nursing | Named in multiple findings including infection preventionist role and abuse reporting |
| Administrator | Administrator | Named in quality assurance and abuse reporting findings |
| Dietary Manager | Dietary Manager | Named in food and beverage preference findings |
| Dietary Aide #1 | Dietary Aide | Named in food and beverage preference findings |
| Medication Aide #2 | Medication Aide | Named in medication storage findings |
| Wound Care Nurse | Wound Care Nurse | Named as former Infection Preventionist |
| Unit Manager | Unit Manager | Named in medication and adaptive equipment findings |
| Speech Therapist | Speech Therapist | Named in food, beverage, and abuse findings |
| Occupational Therapy Assistant | Certified Occupational Therapy Assistant | Named in adaptive equipment findings |
| Medication Aide #1 | Medication Aide | Named in medication storage and adaptive equipment findings |
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 11, 2023
Visit Reason
The inspection was conducted due to a complaint alleging verbal abuse and neglect by Nurse Aide #6 towards Resident #2, and failure to implement physician orders and proper care related to urinary tract infections for Resident #1.
Findings
The facility failed to protect Resident #2 from verbal abuse and neglect by Nurse Aide #6, who refused timely assistance and made threatening gestures. The facility also failed to implement urology physician orders for Resident #1, resulting in delayed antibiotic treatment and subsequent severe sepsis. The facility did not suspend NA #6 immediately after the incident and did not properly transcribe or follow up on medical orders for Resident #1.
Complaint Details
The complaint involved allegations of verbal abuse and neglect by Nurse Aide #6 towards Resident #2 on 7/31/23, including refusal to assist with toileting and verbal threats. The family member filed a formal complaint on 8/1/23. The facility investigation did not substantiate the allegations. Additionally, Resident #1's family reported concerns about untreated urinary tract infections and hallucinations, which were not properly addressed by the facility, leading to severe sepsis and hospitalization on 7/13/23.
Severity Breakdown
Level of Harm - Actual harm: 2
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to protect Resident #2 from verbal abuse and neglect by Nurse Aide #6. | Level of Harm - Actual harm |
| Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft, including failure to remove NA #6 from resident care assignment after abuse incident. | Level of Harm - Actual harm |
| Failure to provide appropriate care for Resident #1 related to urinary tract infections, including failure to implement urology orders and failure to properly collect and process urine specimens. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Date of abuse incident: Jul 31, 2023
Date of complaint filing: Aug 1, 2023
Date of urine specimen collection: Jun 23, 2023
Date of lab pickup: Jun 26, 2023
Date of lab result: Jun 29, 2023
Date of hospitalization: Jul 13, 2023
Duration of Macrobid antibiotic order: 180
Nurse #6 shift hours on 7/31/23: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #6 | Nurse Aide | Named in verbal abuse and neglect incident involving Resident #2 |
| Nurse #6 | Nurse | Intervened during confrontation between NA #6 and Resident #2's family member |
| Assistant Director of Nursing | ADON | Handled investigation of abuse allegations and suspended NA #6 on 8/1/23 |
| Nurse #1 | Agency Nurse | Assigned on 6/9/23, failed to transcribe urology orders for Resident #1 |
| Nurse #2 | Nurse | Worked night shifts, involved in care of Resident #1 and urine specimen collection |
| Nurse #3 | Agency Nurse | Collected urine specimen on 6/23/23 but did not notify lab for pickup |
| Nurse #4 | Nurse | Received urology orders on 7/12/23 but did not collect urine specimen or start antibiotics |
| Nurse #5 | Agency Nurse | Found Resident #1 unresponsive on 7/13/23 and initiated emergency response |
| MA #1 | Medication Aide | Assisted Nurse #5 during emergency response for Resident #1 on 7/13/23 |
| Director of Nursing | DON | Involved in review of orders and communication regarding Resident #1 |
| Nurse Practitioner | NP | Provided medical orders and follow-up care for Resident #1 |
| Physician | MD | Oversaw medical care for Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Jul 11, 2023
Visit Reason
The inspection was conducted following a complaint regarding failure to provide timely incontinence care and respect resident dignity at Clear Creek Nursing & Rehabilitation Center.
Findings
The facility failed to provide timely incontinence care to Resident #3, resulting in actual harm and resident frustration. Additionally, the facility failed to provide preferred bathing methods for Residents #2 and #4, with staff not following shower schedules and residents often receiving bed baths instead of showers.
Complaint Details
The complaint investigation revealed Resident #3 was left sitting in a wet brief for over an hour despite activating her call light multiple times. Staff interviews confirmed lack of awareness or failure to respond appropriately. Resident #3 expressed frustration and anger. The Director of Nursing acknowledged the delay was unacceptable. Additionally, complaints about Residents #2 and #4 not receiving scheduled showers were substantiated, with staff unaware of shower schedules and preferring bed baths.
Severity Breakdown
Level of Harm - Actual harm: 1
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to honor Resident #3's right to dignity by not providing timely incontinence care despite call light activation. | Level of Harm - Actual harm |
| Failure to promote and facilitate resident self-determination through support of resident bathing choice for Residents #2 and #4. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide incontinence care when requested for Resident #3, a dependent resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Observation duration: 73
Scheduled showers per week: 2
Shower refusals documented: 3
Shower refusals documented: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | Observed passing Resident #3's room without answering call light; stated she was not assigned to Resident #3 |
| NA #2 | Nurse Aide | Assigned to Resident #3; unaware Resident #3 needed incontinence care at 11:00 am; assisted Resident #3 to bathroom at 12:51 pm |
| NA #3 | Nurse Aide | Assisted NA #2 with Resident #3; unaware Resident #3 had turned on call light |
| Therapist #1 | Therapist | Walked past Resident #3's call light without answering; reported being task-oriented |
| Therapist #2 | Therapist | Entered Resident #3's room, turned on call light after resident requested care, spoke with nurse aides |
| Director of Nursing | Director of Nursing | Acknowledged Resident #3 should not have waited more than an hour for care; aware Residents #2 and #4 were not receiving scheduled showers; provided verbal in-service to night shift staff |
| NA #5 | Nurse Aide | Worked night shift; unaware of shower schedule; did not give scheduled showers to Residents #2 and #4 |
| NA #6 | Nurse Aide | Worked night shift; unaware of shower schedule; did not give scheduled showers to Residents #2 and #4 |
| NA #7 | Nurse Aide | Worked night shift; stated Resident #4 refused showers; gave bed baths instead |
| Nurse #2 | Nurse | Asked NA #2 to complete care rounds with Resident #3; unaware Resident #3 did not receive incontinence care at 11:00 am |
Inspection Report
Routine
Deficiencies: 8
May 26, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, facility maintenance, assessments, care planning, infection control, and staffing.
Findings
The facility was found deficient in multiple areas including failure to maintain wall integrity and fix plumbing leaks, inaccurate Minimum Data Set (MDS) assessments for several residents, incomplete and untimely care plans, failure to apply prescribed positioning devices, inadequate infection control practices related to glucometer cleaning, improper food storage and labeling, and failure to ensure the Director of Nursing worked full-time as required.
Severity Breakdown
Level of Harm - Potential for minimal harm: 1
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to maintain wall integrity in residents' rooms and failed to fix a leaking toilet in one resident room. | Level of Harm - Potential for minimal harm |
| Failed to code the Minimum Data Set (MDS) assessment accurately in areas including skin conditions, vision, weight loss, dental issues, eating, and range of motion for 5 of 24 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop a comprehensive care plan for non-pressure related skin issues for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and revise care plans timely for palliative care and weight loss for residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate care to maintain or improve range of motion by not applying bilateral elbow rolls as prescribed for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide competency training and ensure proper glucometer cleaning/disinfecting by nurses during medication administration observations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to date opened food items and staff drinks improperly stored in the dietary freezer and nourishment refrigerator; also failed to ensure plastic dishware was stored dry. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the full-time Director of Nursing worked as a full-time DON for required days. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiency count: 8
Resident sample size: 24
Weight records: 10
Days DON worked as staff nurse: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MDS Nurse #1 | MDS Nurse | Interviewed regarding inaccurate MDS assessments and coding errors |
| Maintenance Director | Maintenance Director | Interviewed regarding unreported wall damage and plumbing leaks |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding care plan development, elbow roll application, and nursing responsibilities |
| Nurse #3 | Nurse | Observed and interviewed regarding failure to clean glucometer properly |
| Nurse #4 | Nurse | Observed and interviewed regarding failure to clean glucometer properly |
| Nurse #5 | Nurse | Observed and interviewed regarding failure to clean glucometer properly |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage, labeling, and staff drink in freezer |
| Administrator | Administrator | Interviewed regarding awareness of facility deficiencies and expectations for compliance |
| Occupational Therapist #2 | Occupational Therapist | Interviewed regarding elbow roll use and therapy for Resident #18 and #36 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding nursing staffing and glucometer cleaning education |
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