Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cleveland Pines during CMS and state inspections, most recent first.
Three residents with significant physical and cognitive impairments did not receive appropriate toenail care, as their long, thick, and curling toenails were not addressed through regular nursing assessments or timely podiatry referrals. Staff interviews revealed lapses in communication and follow-up, resulting in these residents not being scheduled for podiatry services despite clear need.
Several severely cognitively impaired residents with significant physical limitations were found with bed rails in use without individualized assessment, documentation of risks and benefits, or informed consent. Staff routinely installed bed rails on all beds as standard practice, often copying previous assessments rather than evaluating current resident needs. Leadership confirmed the absence of physician orders, care plan documentation, and staff training regarding proper bed rail assessment and consent procedures.
A cognitively impaired, nonverbal resident dependent on staff for all ADLs was kicked multiple times by another resident with a history of aggression. The incident occurred in a hallway and was witnessed by a NA, who intervened and reported the event. Staff interviews confirmed the aggressive behavior and the vulnerable status of the resident who was kicked, highlighting a failure to protect residents from abuse.
A facility failed to thoroughly investigate an incident where one resident was observed kicking another nonverbal, cognitively impaired resident. Staff separated the residents and performed an initial assessment, but did not conduct further physical or psychological evaluations, nor did they resolve conflicting staff accounts or document a comprehensive investigation as required by policy.
The facility did not complete required PASRR Level II reviews for three residents who received new mental health diagnoses after admission, despite initial PASRR Level I screenings indicating this was necessary if new diagnoses or significant changes occurred. Staff interviews revealed gaps in awareness and communication regarding the need for timely PASRR Level II completion when residents were newly diagnosed with mental health conditions.
Nursing staff failed to follow infection control protocols during tracheostomy care for two residents with respiratory failure, including not sanitizing hands or changing gloves after handling soiled materials and before performing subsequent steps of care. The Infection Preventionist was present but did not intervene, and both residents were severely cognitively impaired and required tracheostomy care as part of their care plans.
A facility failed to maintain accurate records and reconciliation for a controlled medication when a resident's Ativan inventory sheet and 10 tablets were found missing. Staff interviews confirmed the required documentation could not be located, and the DON acknowledged the records were not retained as per policy. The resident did not report missing any medication, but the administrator expected proper recordkeeping for controlled substances.
Residents expressed feelings of dependence and sadness due to the lack of group outings outside the facility, which had not occurred for almost two years. Despite requests during Resident Council Meetings, outings were not possible due to transportation limitations. The facility's van could only accommodate a few residents at a time and was primarily used for medical appointments, preventing recreational outings.
A facility failed to update a resident's advance directive records, resulting in conflicting code status information between the paper chart and electronic medical record. The resident's family requested a DNAR status due to the resident's poor prognosis, but the paper chart still indicated full resuscitation. Staff interviews revealed a lack of communication and proper documentation procedures, leading to the discrepancy.
A resident with hemiplegia and hemiparesis did not receive a prescribed left-hand splint to prevent further contracture. Despite an order placed by the occupational therapist, the splint was not received, and the resident was observed without it. Interviews revealed a lack of communication and follow-up among staff, including the OT, business office manager, and nurse practitioner, leading to the resident not receiving necessary treatment.
A Treatment Nurse in an LTC facility failed to follow the infection control policy for hand hygiene during a wound care procedure. The nurse did not sanitize her hands after doffing gloves and before donning new ones, contrary to the facility's policy. Interviews revealed a misunderstanding of the policy, and the Infection Preventionist had not audited the nurse during dressing changes.
Failure to Provide Timely Foot Care and Podiatry Services
Penalty
Summary
The facility failed to ensure appropriate foot care for three residents, resulting in untrimmed, thick, and curling toenails, and a lack of timely podiatry services. For each of the three residents, weekly nursing assessments did not document the need for toenail care, and there was no evidence in the electronic medical records that referrals to podiatry had been made or that the residents had been seen by a podiatrist. Observations revealed that all three residents had long, thick toenails, with some nails curling inward or appearing blackened, and staff interviews confirmed that these issues had not been reported or addressed. One resident with a traumatic brain injury and contractures was completely dependent on staff for all activities of daily living and was severely cognitively impaired. Despite this, her toenails were observed to be thick, long, and in poor condition, with no record of podiatry referral or care since admission. Another resident with a left above-the-knee amputation and peripheral vascular disease was also dependent on staff for personal care. His toenails were found to be thick and curling, and although staff recognized the need for podiatry intervention, no referral had been made, and he had not been scheduled for podiatry clinic visits. A third resident with peripheral artery disease and a below-the-knee amputation was similarly dependent on staff and unable to care for her own toenails. Her toenails were observed to be long and curling, and although she had previously refused podiatry care, there was no documentation of follow-up or rescheduling for podiatry services. Interviews with nursing staff, the nurse practitioner, the DON, and the social worker revealed a lack of communication and follow-up regarding residents' toenail care needs. Staff members often could not recall if they had reported the need for podiatry services, and the process for adding residents to the podiatry list was inconsistently followed. The DON and social worker acknowledged that sometimes follow-up did not occur as it should, resulting in residents not receiving necessary foot care.
Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess, document, and obtain informed consent for the use of bed rails for several severely cognitively impaired residents. In multiple cases, residents with significant physical and cognitive impairments, such as bilateral above-knee amputations, contractures, quadriplegia, and severe dementia, were found with bed rails in use without evidence of individualized assessment, documentation of risks and benefits, or informed consent from the resident or their representative. Staff interviews revealed that bed rails were routinely installed on all beds as a standard practice, regardless of individual resident need or ability to use the rails, and that assessments were often completed by copying information from previous assessments rather than through direct evaluation of the resident's current condition. Medical record reviews for the affected residents showed a lack of physician orders for bed rails, absence of care plans addressing bed rail use, and no documentation of discussions regarding the risks and benefits of bed rail use with residents or their representatives. In several instances, the Minimum Data Set (MDS) assessments did not indicate the use of bed rails, and care plans did not address their use, despite their presence on the residents' beds. Staff, including nurses and nurse aides, reported that residents were unable to use the bed rails due to their physical and cognitive limitations, and that the rails were primarily used to assist staff during care or to prevent residents from rolling out of bed, rather than for resident mobility or safety as intended. Interviews with facility leadership, including the DON, NP, and Administrator, confirmed that there was no process in place for obtaining informed consent or physician orders for bed rails, and that staff were not adequately trained on proper assessment procedures. The Administrator acknowledged that the issue was only recognized during the survey and that the facility's practices regarding bed rail assessments and use were not being executed correctly. Observations of the residents confirmed that bed rails were in use for residents who were nonverbal, unable to participate in their care, and physically incapable of using the rails for mobility or safety.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, specifically resident-to-resident abuse. During the incident, a nurse aide (NA) heard yelling and, upon investigation, observed one resident kicking another in a hallway. The resident being kicked was severely cognitively impaired, nonverbal, and dependent on staff for all activities of daily living, with a history of wandering and grabbing objects or other residents' wheelchairs to propel herself. The resident who was kicking was alert, oriented, and had a documented history of being combative and physically aggressive with staff. Multiple staff interviews confirmed that the cognitively impaired resident was attempting to back away but was slow moving and nonverbal, only occasionally singing. The NA immediately separated the residents and notified the unit manager, who assessed the resident and found no visible injuries. The unit manager and other staff noted that the resident being kicked would likely have experienced pain or fear but was unable to communicate her feelings. The aggressive resident admitted to kicking the other resident several times, stating she was defending herself because the other resident would not move away. Documentation and interviews revealed inconsistent accounts among staff regarding whether physical contact occurred, but at least one staff member witnessed repeated contact with the lower legs. The incident was reported to the social worker and nurse practitioner, both of whom were informed that the aggressive resident had a history of such behavior. The facility's failure to adequately supervise and protect the vulnerable resident from abuse by another resident constituted a deficiency in ensuring resident safety and upholding residents' rights.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of resident-to-resident abuse involving two residents, one of whom had significant cognitive and physical impairments, including dementia, Parkinson's disease, and nonverbal status. The incident occurred when a nurse aide overheard yelling, entered the hallway, and observed one resident kicking another, who was attempting to back away but was slow moving and nonverbal. The nurse aide immediately separated the residents and notified the unit manager, who performed an initial assessment and found no visible injuries. However, no further assessments were conducted to evaluate for delayed physical injuries or mental anguish, despite the nonverbal resident's grimacing during the incident. Documentation and staff interviews revealed inconsistencies in the accounts of the incident, with some staff stating that physical contact occurred and others stating it did not. The facility's policy required a thorough investigation of all abuse allegations, including interviews with all involved parties and assessments for both physical and psychological harm. Despite this, the investigation folder lacked statements from all potential witnesses, did not address conflicting accounts, and did not include follow-up assessments for injuries that may have appeared later or for possible mental distress. Key staff, including the social workers and the administrator, did not initiate a formal investigation, citing the absence of injury as the reason. The administrator and social workers did not amend their statements to resolve discrepancies or document further inquiry, even after one resident admitted to kicking the other. The director of nursing was not directly informed, and there was no evidence that the incident was reported to required authorities as per facility policy. The lack of a comprehensive investigation and documentation failed to meet regulatory requirements for abuse prevention and response.
Failure to Complete PASRR Level II for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level II was completed for residents who received new mental health diagnoses, as required. For three residents, medical record reviews showed that although PASRR Level I screenings were completed prior to admission, subsequent new diagnoses of mental health conditions such as anxiety disorder, mood affective disorder, schizophrenia, post-traumatic stress disorder (PTSD), bipolar disorder, and major depressive disorder were documented in the electronic medical records. Despite these new diagnoses, no PASRR Level II reviews were completed for these residents, contrary to the recommendations noted in their initial PASRR Level I screenings, which specified that a Level II should be resubmitted if a new mental health diagnosis was suspected or if there was a significant change in condition. Staff interviews revealed a lack of awareness and understanding regarding the requirement to complete PASRR Level II reviews upon admission, readmission, or when a new mental health diagnosis was made. The social worker responsible for PASRR paperwork indicated she typically only completed Level II reviews for residents with limited Level II status or when there were changes in behaviors, and was not always informed of new mental health diagnoses. The administrator confirmed her understanding that PASRR Level II should be completed in a timely manner under these circumstances, but this was not consistently implemented for the residents in question.
Failure to Follow Infection Control During Tracheostomy Care
Penalty
Summary
The facility failed to adhere to infection control standards during tracheostomy care for two residents with respiratory failure and tracheostomy status. In both cases, nursing staff did not sanitize their hands or change gloves at critical points during the procedure, despite handling visibly soiled materials and moving between different steps of care. Specifically, one nurse removed soiled tracheostomy ties and neck collar, handled the inner cannula, and inserted a new cannula without changing gloves or sanitizing hands. The same gloves were used to handle clean supplies after touching contaminated items, and the nurse only sanitized hands after completing the entire procedure and doffing gloves and gown. A second nurse also failed to change gloves or sanitize hands after inserting a new inner cannula and before cleaning around the stoma, removing soiled dressings, and replacing the neck strap and ties. This nurse continued to perform multiple steps of tracheostomy care, including handling soiled and clean items, without changing gloves or sanitizing hands. In both cases, the Infection Preventionist assisted but did not intervene to correct the infection control breaches during the procedures. Both residents involved were severely cognitively impaired and required ongoing tracheostomy care as part of their care plans. The observations were corroborated by staff interviews, where the nurses acknowledged the lapses in infection control and the Infection Preventionist confirmed awareness of the required procedures. The Director of Nursing stated an expectation that all infection control procedures be followed during tracheostomy care.
Failure to Maintain Accurate Controlled Substance Records and Reconciliation
Penalty
Summary
The facility failed to maintain effective systems for the accurate reconciliation and recordkeeping of controlled medications for one resident. Specifically, the controlled declining inventory sheet for a resident's Ativan 0.5mg tablets, received on a specified date, was missing and could not be located by the facility. The facility's policy required a separate, accurately maintained declining inventory record for each controlled substance, to be reconciled at each shift change by two licensed nurses and retained for at least three years. However, the required documentation for the resident's Ativan was not available for review, and the facility was unable to produce the sheet when requested. Interviews with staff revealed that a nurse discovered the resident's card containing 10 Ativan tablets was missing from the locked controlled substance drawer, while the inventory sheet remained in the nurse's book. The incident was reported to the DON, who confirmed the inventory sheet for the dispensed Ativan could not be found and acknowledged the requirement to retain such records. The missing medication was never recovered, and the resident did not recall missing any doses or having concerns about her medication. The administrator stated an expectation for accurate maintenance of controlled medication records in accordance with facility policy.
Lack of Group Outings for Residents
Penalty
Summary
The facility failed to provide group activities outside of the facility for residents who expressed the importance of such activities. This deficiency was identified through record reviews, activity calendars, and interviews with residents and staff. The facility's activity calendars from January 2024 to July 2024 showed no scheduled outings outside the facility, despite residents' requests during Resident Council Meetings from April 2023 to June 2024. Residents expressed feelings of dependence, sadness, and depression due to the lack of outings, which they had not experienced for almost two years. Several residents, including those identified as Residents #58, #8, #53, #20, #63, and #16, were interviewed and reported that they had repeatedly requested group outings during resident council meetings. They were informed that outings were not possible due to the lack of a suitable van for group transportation. These residents emphasized the importance of outings for their independence and socialization, expressing a desire to shop and dine outside the facility. The absence of these activities contributed to their feelings of sadness and dependence. Interviews with the Activities Director and the Administrator revealed that the facility's current van could only accommodate two to three residents at a time, and there was only one van driver available. The van was primarily used for medical appointments, and logistical challenges prevented its use for recreational outings. Although the facility had initiated a Make a Wish program for individual resident requests, no group outings had been organized. The Administrator acknowledged the residents' requests and the limitations faced in fulfilling them.
Failure to Update Advance Directive Records
Penalty
Summary
The facility failed to update and clarify the medical records to reflect the desired advance directive for a resident reviewed for code status. The resident was admitted to the facility with a Medical Orders for Scope of Treatment (MOST) form indicating full resuscitation, signed by both the resident and a Nurse Practitioner. However, a subsequent physician's order in the electronic medical record indicated a Do Not Attempt Resuscitation (DNAR) status, following discussions with the resident's family who were aware of the resident's decline and poor long-term prognosis. Interviews with facility staff revealed discrepancies between the paper chart and electronic medical record regarding the resident's code status. Nurse #1 was initially unaware of the DNAR order in the electronic record and relied on the paper chart, which still indicated full code status. Unit Coordinators acknowledged the conflicting directives and noted that the process for updating code status was not followed, as a new MOST form was not completed when the DNAR order was made. The Director of Nursing confirmed that the physician did not communicate the change in code status to the nursing staff, and the necessary documentation was not updated to reflect the family's wishes.
Failure to Provide Prescribed Hand Splint for Resident
Penalty
Summary
The facility failed to follow a physician's order to provide and apply a left resting hand splint for a resident with limited range of motion due to hemiplegia and hemiparesis. The resident, who was cognitively intact and had no refusals of care, was observed without the necessary splint on multiple occasions. The occupational therapist had evaluated the resident and determined the need for a new left-hand splint, as the current one did not fit properly. Despite placing an order for the splint with the business manager, the splint had not been received, and the resident had not begun occupational therapy services to address the contracture. Interviews with facility staff revealed a lack of communication and follow-up regarding the missing splint. The occupational therapist admitted to not checking on the order status, while the business office manager was unaware that the splint had not been received. The nurse practitioner, upon realizing the resident did not have the splint, suggested a temporary solution but noted that the resident should have been receiving treatment for the contracture. The Director of Nursing and the Administrator were also unaware of the situation, indicating a failure in ensuring the resident received the prescribed care.
Infection Control Policy Violation During Wound Care
Penalty
Summary
The facility failed to adhere to its infection control policy regarding hand hygiene during a wound care procedure for a resident. The Treatment Nurse did not perform hand hygiene as required by the facility's policy after doffing gloves and before donning a new pair. Specifically, after preparing the dressing with antimicrobial skin and wound gel, the nurse removed her gloves but did not sanitize her hands before putting on a new pair of gloves to remove the old dressing from the resident's wound. This lapse in protocol was observed during a wound treatment session. Interviews conducted with the Treatment Nurse, the Infection Preventionist (IP), and the Director of Nursing (DON) revealed a misunderstanding and lack of compliance with the hand hygiene policy. The Treatment Nurse believed it was acceptable to change gloves without sanitizing her hands if she had not yet touched the resident. The IP confirmed that handwashing audits are conducted, but the Treatment Nurse had not been specifically audited during dressing changes. The DON expressed that it was expected for all staff to follow the handwashing policy, emphasizing the importance of sanitizing hands after glove removal.
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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 Shelby
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| White Oak Manor-shelby | 1.5 mi | ★★★★★ | 6 | 0 |
| Carolina Care Health And Rehabilitation | 9.7 mi | ★★★★★ | 0 | 0 |
| White Oak Manor-kings Mountain | 11.5 mi | ★★★★★ | 13 | 1 |
| Peak Resources- Shelby | 11.5 mi | ★★★★★ | 7 | 0 |
| Peak Resources-cherryville | 11.7 mi | ★★★★★ | 0 | 0 |
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