Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clear Creek Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Improper Food Storage and Spoiled Items in Kitchen Storage Areas: Surveyors found spoiled produce in the walk-in cooler, including moldy strawberries, blueberries, oranges, and wilted squash, zucchini, mushrooms, lettuce, and thyme. In the walk-in freezer, multiple items were open, exposed, or unlabeled and undated, including french fries, hamburger meat, hush puppies, chicken breasts, gluten-free bread, and pancakes. Interviews with the DM, Kitchen Mgr, Cook's Asst, and Admin confirmed food should be labeled, dated, and discarded when spoiled, but these items remained stored as observed.
Missed ordered wound dressing changes: A resident with a stage 4 sacral pressure ulcer, Lewy body neurocognitive disorder, immobility, and total incontinence did not receive daily ordered wound care as documented. The TAR showed the treatment was missed on two days, and during observation the sacral dressing was still dated from several days earlier. The nurse said she was busy and overlooked the dressing changes on the TAR, and the DON and Administrator were unaware the ordered care had not been completed.
An in-use Lantus Solostar insulin pen on the 200-hall med cart was found without an opened date or expiration date. An RN stated insulin pens should be dated when opened and discarded 28 days later, but was unsure when the pen had been opened or why it was not dated. The DON and Administration stated staff were expected to label and date medications when opened.
A resident with a documented pineapple allergy was served a dessert containing pineapple during lunch. The resident’s tray ticket listed allergies to pineapple and tree nuts, and the resident said she was hesitant to eat the cake because of her allergies. A nurse removed the dessert after the surveyor intervened, and staff interviews showed the NAs and dietary leadership expected tray servers to read dietary tickets for allergy information.
A resident with a sacral pressure ulcer had repeated missing nurse initials on the TAR for ordered dressing changes over several months. Nurses stated they had completed the wound care but did not always sign the TAR because they were busy or forgot, and in some cases another nurse may have completed the dressing change. The DON stated completed care was expected to be documented in the TAR, and the Administrator said staff were expected to document properly.
The facility did not provide documented resolution to grievances raised by residents during multiple Resident Council meetings, including concerns about unanswered call lights, maintenance issues, and staff conduct. Residents reported that their concerns remained unresolved and that resolutions were not discussed in meetings. The Activity Director admitted to not documenting resolutions, and the Administrator was unaware of the status of these grievances.
The facility did not maintain accurate and complete medical records, as psychiatric progress notes for several residents were missing from the EMR despite ongoing psychiatric services, and a nurse inaccurately documented the removal of an indwelling urinary catheter in the MAR when the catheter remained in place. Staff interviews and record reviews confirmed these documentation failures, affecting residents with significant cognitive and psychiatric needs.
Staff failed to perform required hand hygiene during meal service, did not consistently use gowns as part of Enhanced Barrier Precautions when providing care to a resident with a G-tube, and did not change gloves or perform hand hygiene during a dressing change for a resident with a PEG tube. These lapses occurred despite facility policies and posted instructions, with staff citing being rushed or not thinking about the protocols at the time.
A resident with a history of pressure ulcers did not have an indwelling urinary catheter removed as ordered by the physician, and documentation inaccurately indicated the removal had occurred. The catheter and drainage bag remained in place, and during observation, the drainage bag and tubing were found lying on the floor instead of being secured, increasing infection risk. Staff interviews revealed confusion about responsibilities and a lack of adherence to proper catheter care protocols.
A resident who was originally admitted with a PASRR level I later received new mental health diagnoses, including depression and delusional disorder. Despite these changes, staff did not complete a required PASRR level II referral, and the oversight was confirmed during interviews with the Social Worker and Administrator, both of whom were unaware that the assessment had not been performed.
A resident with chronic lung disease was receiving continuous oxygen therapy without a current physician order, despite being assessed as needing oxygen and having a care plan specifying its use. Staff interviews and record review confirmed the absence of an active order to guide oxygen administration and equipment changes.
The facility did not complete required annual performance reviews for two nurse aides, as shown by missing documentation and staff interviews. The SDC, responsible for monitoring these reviews, did not recall receiving notifications for the overdue reviews, and both the DON and Administrator confirmed the SDC's responsibility for ensuring completion.
Improper Food Storage and Spoiled Items in Kitchen Storage Areas
Penalty
Summary
Food storage practices in the kitchen were deficient in the walk-in cooler and walk-in freezer. During an initial kitchen tour with the Dietary Manager, surveyors observed multiple spoiled or deteriorated food items in the walk-in cooler, including strawberries with a white, fuzzy substance, a visibly spoiled strawberry, blueberries with a white, fuzzy substance, wilted and brown yellow squash and zucchini, oranges with a white, fuzzy substance, dark brown and wilted mushrooms, and unopened packs of lettuce and thyme that were dark brown, mushy, and contained liquid inside the bags. These items were found stored in their original packaging or in boxes while showing signs of spoilage. In the walk-in freezer, surveyors observed food items that were open, exposed, or not labeled and dated, including french fries in an unlabeled resealable bag with no open date, hamburger meat in an unlabeled resealable bag with no open date and visible ice crystals, hush puppies with no open date, chicken breasts stored open and exposed with no open date and visible ice crystals, unopened gluten-free bread labeled with an open date of 12/04/2024, and open pancakes with no open date. Interviews with the Dietary Manager, Kitchen Manager, Cook's Assistant, and Administrator confirmed that food items should be labeled and dated when opened or removed from original packaging and that wilted or moldy items should be discarded, but the observed items remained in storage at the time of the survey.
Missed ordered wound dressing changes
Penalty
Summary
The facility failed to change a prescribed pressure ulcer dressing as ordered for a resident with a stage 4 sacral pressure ulcer. The resident was readmitted with diagnoses including stage 4 sacral pressure ulcer, neurocognitive disorder with Lewy Bodies, abnormal posture, and COPD, and was admitted to hospice care. The care plan identified the sacral wound as related to pressure, friction, incontinence, and immobility, with interventions including ordered treatments, enhanced barrier precautions, routine turning and repositioning, perineal care after incontinence, and use of a special mattress. The resident’s MDS showed she was dependent on staff for toileting, hygiene, showering, dressing, and rolling, and was always incontinent of bowel and bladder. A physician ordered daily wound care to clean the sacral wound with normal saline, pat dry, apply calcium alginate, and cover with a bordered dressing. The wound flow sheet documented the wound as 2 cm x 0.8 cm x 0.7 cm with scant serous drainage and granulation tissue. The TAR showed the treatment was not documented as completed on two consecutive days, and during observation the dressing was found dated from several days earlier. The nurse who worked those days stated she should have completed the dressing changes but missed them because she was busy and did not complete the wound care when reviewing the TAR. The DON and Administrator were not aware the ordered dressing changes had not been completed.
Unlabeled In-Use Insulin Pen
Penalty
Summary
The facility failed to label an in-use Lantus Solostar insulin pen with the opened date and expiration date information for 1 of 4 medication carts, the 200-hall medication cart. During an observation of the cart with Nurse #5, one opened and in-use insulin pen was found stored in a clear zippered bag labeled with the resident's name and prescribing information, but it was not dated with the date it was opened or an expiration date. Nurse #5 stated insulin pens were supposed to be dated when opened and discarded 28 days after opening, but she was unsure when the pen had been opened or why it was not dated. The DON stated she expected nursing staff to label insulin pens with the date opened and discard them 28 days after the opened date, and Administration stated staff were expected to label and date medications when opened.
Failure to Honor Documented Food Allergy During Meal Service
Penalty
Summary
The facility failed to provide food that accommodated a documented pineapple allergy for one resident. The resident was cognitively intact and had food allergies listed in the electronic health record as pineapple and tree nuts, with the care plan also noting those allergies. A history and physical note documented a pineapple allergy with abdominal pain as the reaction. The lunch menu posted in the dining room listed pineapple upside-down cake as the dessert, and the resident’s meal tray ticket also identified allergies to pineapple and tree nuts. During lunch observation, the resident was eating a piece of cake with pineapple topping and stated she was hesitant to eat it because she had allergies and did not know what was on the cake. The surveyor intervened, and a nurse removed the dessert from the tray. The nurse then confirmed the cake contained pineapple and asked the resident if she felt okay; the resident said she felt fine and thought pineapple had upset her stomach in the past. The nurse later reported contacting the provider and administering Benadryl, and staff interviews showed the NAs who served the meal denied giving the cake, while the Dietary Manager and RD stated staff handing out trays were responsible for reading dietary tickets to identify allergies and food preferences.
Incomplete Wound Care Documentation
Penalty
Summary
The facility failed to ensure the medical record was complete for wound care documentation for one resident with a sacral pressure ulcer. Review of the resident’s TAR showed multiple missing nurse initials for sacral dressing changes across March, April, and May 2026, indicating that the wound care entries were not consistently documented in the record. The deficiency involved repeated blank TAR entries for the ordered dressing change, including several dates in each month reviewed. During interviews, multiple nurses stated they had worked with the resident and believed they had completed the sacral dressing changes on the dates in question, but acknowledged that they did not always sign the TAR because they were busy or forgot. One nurse stated another nurse completed the dressing change on a date when the supplies were available, and another nurse said a different nurse split the shift and completed the care. The DON stated that if a nurse completed a dressing change, it was expected to be documented in the TAR, and the Administrator stated that all staff were expected to document properly.
Failure to Document and Resolve Resident Council Grievances
Penalty
Summary
The facility failed to provide documented resolution to grievances raised during four out of six monthly Resident Council meetings. Concerns noted in the meeting minutes included issues such as music not being played during meals, assistance to the beauty shop, displaying DNR status above beds, unanswered call lights, problems with nursing staff, maintenance issues with sinks and toilets, missing laundry, rooms needing painting, and nursing staff being loud at night. For each of these meetings, there was no evidence in the follow-up documentation that the facility responded to or resolved the grievances voiced by residents. Interviews with several residents confirmed that the concerns raised during Resident Council meetings remained unresolved and that the Activity Director did not discuss resolutions at subsequent meetings. The Activity Director acknowledged failing to document resolutions in the meeting minutes, despite reporting verbally to residents about how concerns were being addressed. The Social Worker reported not receiving any resident council grievances since August, and the Administrator was unaware if grievances from Resident Council meetings were being completed and resolved, though he expected such documentation to be included in the minutes.
Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, specifically regarding psychiatric progress notes and medication administration documentation. For four residents with significant cognitive impairments and psychiatric diagnoses, psychiatric progress notes were missing from their electronic medical records (EMR), despite ongoing psychiatric services and physician orders for evaluation and treatment. Although hard copies of the psychiatric visit notes were available upon request, these notes had not been uploaded to the residents' EMRs as required. Interviews with the Social Worker, Medical Records Clerk, Director of Nursing (DON), and Administrator revealed that none could explain the absence of these notes in the EMR, and the process for ensuring their inclusion was not followed during a period when the Social Worker was absent from the facility. Additionally, the facility failed to accurately document the completion of a physician's order regarding the removal of an indwelling urinary catheter for another resident. The medication administration record (MAR) indicated that the catheter was removed by a nurse on the specified date, but subsequent observation showed the catheter was still in place, and there were no new orders to reinsert it. The nurse listed as having completed the order did not recall removing the catheter and could not explain the documentation discrepancy. The DON was unaware that the order had not been carried out as documented. These deficiencies were identified through record reviews, staff interviews, and direct observation, affecting all residents reviewed for accurate medical records. The facility's failure to maintain up-to-date and accurate documentation in the EMR and MAR resulted in incomplete records for residents receiving psychiatric care and those with specific physician orders for medical interventions.
Failure to Follow Infection Control and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols during multiple observed care activities. One nursing assistant did not perform hand hygiene between meal deliveries, including after assisting residents with food, drinks, and over-the-bed tables, despite the facility's handwashing policy requiring hand hygiene between resident contacts and tasks. The nursing assistant acknowledged awareness of the policy but stated she was focused on delivering meals quickly and did not think to use hand sanitizer during the process. The Director of Nursing confirmed there was no supervision during meal service to monitor hand hygiene compliance. In another instance, a nurse providing enteral feeding to a resident with a gastrostomy tube did not don a gown as required by the facility's Enhanced Barrier Precautions (EBP) policy, which mandates both gloves and gowns for high-contact care activities involving indwelling medical devices. The nurse performed hand hygiene and applied gloves but omitted the gown, only correcting this after being prompted to review the EBP instructions posted on the resident's door. The nurse admitted she was aware of the EBP requirements but did not apply them due to being in a rush. Additionally, during a dressing change for a resident with a PEG tube, a nurse removed gloves after applying a new dressing and, without performing hand hygiene or donning new gloves, used her bare hand to stabilize the dressing while writing on it with a pen. The nurse stated she did not want to touch her pen with contaminated gloves and acknowledged she should have changed gloves before handling the pen and the dressing. The Director of Nursing and the Nurse Practitioner both stated that staff are expected to follow the facility's infection control and EBP policies during resident care.
Failure to Remove Indwelling Urinary Catheter and Maintain Proper Catheter Care
Penalty
Summary
A deficiency occurred when a resident with a history of stage 3-4 pressure ulcer and an indwelling urinary catheter did not have the catheter removed as ordered by the physician. The care plan indicated the catheter was to be removed on a specific date, and the order was entered into the electronic medical record. However, the assigned nurse did not remove the catheter on the scheduled date, and documentation incorrectly reflected that the removal had been completed. Multiple staff interviews revealed confusion regarding who was responsible for the removal, and the catheter remained in place beyond the ordered removal date. Additionally, during an observation, the resident was found in bed with the indwelling urinary catheter and drainage bag still in place, and the catheter tubing and drainage bag were lying on the floor beside the bed. Staff interviews confirmed that the drainage bag should have been secured under the bed frame and not touching the floor, as this practice increases the risk of infection. There was uncertainty among staff about who last emptied and secured the drainage bag, but it was confirmed that the bag was not properly positioned at the time of observation. The nurse practitioner and director of nursing both confirmed that the catheter should have been removed as ordered and that the drainage bag should not have been on the floor. The administrator also acknowledged that the order for catheter removal should have been completed on the specified date and that catheter tubing and drainage bags should not be in contact with the floor due to infection risk.
Failure to Complete PASRR Level II Referral After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level II referral was made for a resident who received new mental health diagnoses. Record review showed that the resident was originally admitted with a PASRR level I completed, but subsequently received diagnoses of depression, delusional disorder, and insomnia. Despite these new mental health diagnoses, the resident's most recent comprehensive Minimum Data Set (MDS) did not indicate a level II PASRR assessment. Interviews with the Social Worker and Administrator confirmed that a PASRR level II referral should have been completed upon the addition of new mental health diagnoses or a change in condition, but this was not done for the resident. Both staff members were unaware that the required assessment had not been performed.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician order for oxygen therapy for a resident with chronic lung disease and hypertension. Upon admission, the resident was assessed as requiring oxygen therapy, and the care plan specified administration of oxygen at 2 liters per minute by nasal cannula. However, a review of the physician orders revealed there was no active order for oxygen therapy, despite the resident receiving oxygen since admission. Observations confirmed the resident was receiving oxygen at varying flow rates, and the responsible party stated the resident required continuous oxygen due to his lung disease. Interviews with facility staff, including the Nurse Practitioner, a nurse, and the Director of Nursing, revealed they were unaware that there was no current physician order for the oxygen therapy being administered. Staff acknowledged that a physician order was necessary to specify the flow rate and instructions for changing the nasal cannula and tubing. The deficiency was identified through observations, record review, and interviews, which confirmed the lack of a required physician order for the ongoing oxygen therapy.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews for two of five nurse aides reviewed, as required. Record reviews showed that one nurse aide, hired in August 2021, had no documented performance review from January 2024 to the present, and another aide, hired in May 2023, also lacked a documented review for the same period. Both aides reported in interviews that they did not recall having a performance review completed during their employment. The Staff Development Coordinator (SDC), who began working in August 2024, stated that performance reviews were part of the facility's online education program, with email notifications sent when reviews were due. The SDC indicated that nurse aides were responsible for printing the review, having it completed by a nurse, and returning it for filing. However, the SDC did not recall receiving notifications for the two aides in question and could not explain the absence of completed reviews. The Director of Nursing and the Administrator both confirmed that the SDC was responsible for monitoring and ensuring completion of annual performance reviews.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mint Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wilora Lake Healthcare | 6.2 mi | ★★★★★ | 10 | 0 |
| Redwood Health & Rehab | 6.4 mi | ★★★★★ | 6 | 0 |
| Asbury Health And Rehabilitation Center | 7.5 mi | ★★★★★ | 0 | 0 |
| Royal Park Rehabilitation & Health Center | 7.5 mi | ★★★★★ | 8 | 0 |
| Willowbrooke Court Sc Ctr At Matthews Glen | 7.5 mi | ★★★★★ | 0 | 0 |
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