Premises Information


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Name

CLEAR CREEK NURSING AND REHABILITATION CENTER

Address

10506 CLEAR CREEK COMMERCE DR

City/State/ZIP

MINT HILL

28227

Premise Type

40 - Rest/Nursing Homes

County

Mecklenburg

Inspection Date

1/25/2017

Final Score @ Grade

94.50

General Comments

Roy Culp (Maintenance), and Thomas McNeal(EVS) were present during the inspection. Dan Goodwin accepted the report. 8. CONTINUED FORM PAGE 2 Observed the bathtub in the therapy restroom with several dead drain flies. **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). No point deduction for the following: 9. Observed wheel chairs, sitting chairs, therapy wedge were stored in the 500 hall community spa. **Toilet rooms shall not be used for storage. See rule .1312 (b). Observed a damaged unreadable hand wash sink the women's main hall restroom. **Keep hand washing signs posted in all staff restrooms. 15A NCAC 18A .1312 (b). 12. Observed the sink without soap in the laundry room, and the paper towels were inaccessible in the med prep room (service hall). **Provide liquid soap and disposable towels at all hand washing sinks. 15A NCAC 18A .1312 (d). 15. Provide documentation that the hair bowl faucet in the salon is equipped with back flow prevention. **Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d). 16. Updated back-up water supply plan submitted and will be filed. 18. Observed the water pitcher on the med carts with sticky residue, and one staff member stated the water pitcher was rinsed with hot water only. **All multi-use drinking water utensils shall be cleaned and sanitized between users. 15A NCAC 18A .1314 (a). Observed 26. Observed cardboard, wooden pallets and other items collect around the recycling dumpster. **The premises shall be kept neat, clean, and free of litter. 15A NCAC 18A .1317 (c). 28. Observed boxes of paper towels and toilet paper were stored on the floor in the EVS, and personal items stored on the sink counters within the "splash zone" in shared resident room. **Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a). 33. Observed soiled sheet on one resident bed in room 207. 35. Observed hair left in hair rollers in the hair salon. **Patient contact items that become contaminated during use shall be cleaned and disinfected after each use. 15A NCAC 18A .1319 (c). 36. Observed the refrigerator gasket was separating from door in 300/400 kitchen. **Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c). 40. Observed resident food was not labeled in the 100/200 kitchen and 500/600 kitchen. **Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply and shall be labeled with the name of the person to receive the food and the date the food was brought into the facility. 15A NCAC 18A .1321 (b).

Violations

CDI=Corrected During Inspection

R=Repeat Violation

VR=Verification Required

Violation Item	Demerits	Violation Description	CDI	R	VR	Comments
3	1	Walls and ceilings cleanable, clean, good repair	No	No	No	Observed wall damage behind the bed in room 106, the wall at the soap dispenser damaged in the women's main hall restroom, and several settlement cracks in the walls throughout the facility. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
4	1	Lighting at least 10 foot candles 30 inches above floor	No	No	No	Observed lights were not functioning in several area (less than 10 foot candles of light): med prep (service hallway), room 109, 100/300 spa, staff restroom (med prep), room 307 restroom, central supply, therapy restroom, janitor closet (laundry), the chapel, janitor closet (service hall), 500/700 med room restroom. **All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a).
8	1	Facilities conveniently located, clean and in good repair	No	No	No	Observed the hopper was soiled in the service hall soiled utility room, an elevated toilet chair with rust in room 307, an elevated toilet chair was soiled in room 607, a soiled toilet basin and "urine hat" in the clean utility room, and some toilet seats were loose and needed securing. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed the sink was not clean in the service hall med prep room, the faucet aerator stricting the flow of water at the hand sink in the service hall med room and clean utility, the sink was not clean in 100/200 med prep, slow draining sink in room 109 and 207, and the sink was not clean in the laundry room. Keep all hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
10	0.50	Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected	No	No	No	Observed several bed pans that were not clean and/or were not labeled with the resident's name: room 806, room 402, room 508. Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). All bedpans/urinals/emesis basins shall be cleaned after each use. 15A NCAC 18A .1312 (c).
19	1	Ice protected, dispensed, equipment clean in good repair	No	No	No	Observed the ice machine shoots with pink residue in the 100/200 hall, 300/400 hall, and 500/600 hall. **Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b).
32	1	Furniture clean and in good repair. Mattresses clean, dry, odor free	No	No	No	Observed several rooms with couches/chairs needed cleaning in room 207, handle broken on a bedside table in room 109, mattress needed cleaning in rooms 303, 207, 307 (urine odor), some window blinds were dusty, and patio furniture needed pressure washing. All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). Mattresses shall be kept clean, dry, and odor free. 15A NCAC 18A .1319 (a).