Cycle 1
Health 2025-11-18 · Fire 2024-07-18
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Shelby, NC
Cleveland Pines
3-star overall rating with 3-star inspections with $5,000 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1404 N Lafayette Street, Shelby, NC
(980) 487-1500
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atrium Health
Operator or chain grouping
Approved since
1988-06-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.43
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.28
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.81
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,920
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.31% · Performance 22.32% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.49
Baseline 7.75% · Performance 7.09% · Measure score 2.49 · Achievement 2.49 · Improvement 1.9
Total nurse turnover
7.34
Baseline 37.21% · Performance 33.70% · Measure score 7.34 · Achievement 7.34 · Improvement 2.34
Adjusted total nurse staffing
1.52
Baseline 3.86 hours · Performance 3.51 hours · Measure score 1.52 · Achievement 1.52 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.3% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 99 · Observed rate 6.06% · Lower 95% interval 6% |
| Discharge to community | 58.41% |
50.57%
7.8 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 56.79% · Lower 95% interval 48.68% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 52.27% |
95.27%
43 pts worse
|
Numerator 46 · Denominator 88 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 88 |
| Discharge self-care score | 43.94% |
53.69%
9.8 pts worse
|
Numerator 29 · Denominator 66 |
| Discharge mobility score | 34.85% |
50.94%
16.1 pts worse
|
Numerator 23 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 2.3% |
2.29%
About the same
|
Numerator 2 · Denominator 87 · Adjusted rate 2.4% |
| Healthcare-associated infections requiring hospitalization | 7.09% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 69 · Observed rate 5.8% · Lower 95% interval 3.8% |
| Staff COVID-19 vaccination coverage | 2.44% |
8.2%
5.8 pts worse
|
Numerator 3 · Denominator 123 |
| Staff flu vaccination coverage | 96.43% |
42%
54.4 pts better
|
Numerator 135 · Denominator 140 |
| Discharge function score | 39.39% |
56.45%
17.1 pts worse
|
Numerator 26 · Denominator 66 |
| Transfer of health information to provider | 24.24% |
95.95%
71.7 pts worse
|
Numerator 8 · Denominator 33 |
| Transfer of health information to patient | 60.53% |
96.28%
35.8 pts worse
|
Numerator 23 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 10.42% |
25.2%
14.8 pts worse
|
Numerator 5 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.8% |
91.5%
3.3 pts better
|
93.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 86.7% · Q3 94.3% · Q4 100.0% · 4Q avg 94.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
3.6%
3 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
4.8%
4.2 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
7.2%
5.3 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.7% · Q3 2.5% · Q4 1.2% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.4% |
21.6%
9.8 pts worse
|
19.6%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 30.7% · Q3 26.8% · Q4 32.1% · 4Q avg 31.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.7% |
15.0%
9.3 pts better
|
16.7%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 5.4% · Q3 5.3% · Q4 4.8% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.8% |
21.5%
2.7 pts better
|
16.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.1% |
16.8%
4.3 pts worse
|
14.9%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 15.5% · Q3 25.0% · Q4 16.7% · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
2.6%
About the same
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.7% · Q3 2.3% · Q4 3.3% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
21.2%
1.4 pts worse
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 13.5% · Q3 26.4% · Q4 18.9% · 4Q avg 22.6% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
6.0%
1.1 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.4% · Q3 5.5% · Q4 4.9% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
79.9%
14 pts better
|
81.7%
12.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 92.9% · Q3 93.4% · Q4 98.0% · 4Q avg 93.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
13.2%
3.2 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 9.5% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
78.1%
15.7 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
22.9%
2.8 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 17.9% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-18 · Fire 2023-03-23
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-03-23 · Fire 2021-06-10
3 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-07-18
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-07-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-07-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-27
D · Potential for more than minimal harm
2023-03-23
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2023-05-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-18
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-12-16
E · Potential for more than minimal harm
2025-11-18
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-11-18
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-11-18
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-11-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-11-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-16
E · Potential for more than minimal harm
2024-07-18
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-18
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-08-15
D · Potential for more than minimal harm
2024-07-18
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-08-15
D · Potential for more than minimal harm
2024-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-15
E · Potential for more than minimal harm
2023-03-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-23
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-30
Penalties and ownership
What sits behind the stars
$5,000
2023-03-23
Fine
Fine · fine $5,000
Fine
Ownership
Ball, Rodney
Corporate Director · Individual
Ball, Rodney
Corporate Officer · Individual
Dotson, Kathryn
Contracted Managing Employee · Individual
Haynes, Kenneth
Corporate Director · Individual
Haynes, Kenneth
Corporate Officer · Individual
Murray, Robert
Contracted Managing Employee · Individual
Rissmiller, Scott
Corporate Director · Individual
The Charlotte-Mecklenburg Hospital Authority
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Peak Resources- Shelby
Shelby, NC
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
White Oak Manor-Shelby
Shelby, NC
2-star overall rating with 2-star inspections with $42,637 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Carolina Care Health and Rehabilitation
Cherryville, NC
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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