Provider Name: CLEVELAND PINES
Address: 1404 N LAFAYETTE STREET, SHELBY, NC 28150
Phone: (980) 487-1500
County: Cleveland (220)
Ownership Type: Non profit - Corporation
Certified Beds: 120
Average Residents Per Day: 95.2 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: AHSNF, INC.
First Approved Date: June 30, 1988
Affiliated Entity: ATRIUM HEALTH (55)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 4 ()
Health Inspection Rating: 4 ()
QM Rating: 2 ()
Long Stay QM Rating: 1 ()
Short Stay QM Rating: 2 ()
Staffing Rating: 3 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 1.94129, LPN Staff Hours Per Day: 0.9259, RN Staff Hours Per Day: 0.4452, Licensed Staff Hours Per Day: 1.3711
Total Nurse Staff Hours Per Day, per resident: 3.31242
Weekend Nurse Staff Hours: 3.01435, Weekend RN Staff Hours: 0.1303
PT Staff Hours Per Day, per resident: 0.0157
Nurse Staff Turnover: 39.1, Nurse Turnover Note:
RN Turnover: 0.0, RN Turnover Note:
Admin Left Number: 0, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.0806, Case Mix LPN Hours Per Day: 0.7038, Case Mix RN Hours Per Day: 0.3717
Adjusted Nurse Aide Hours Per Day, per resident: 1.90081, Adjusted LPN Hours Per Day: 0.9708, Adjusted RN Hours Per Day: 0.4513
Total Adjusted Nurse Hours Per Day, per resident: 3.30806
Adjusted Weekend Nurse Hours Per Day, per resident: 3.01038
Health Survey Dates and Scores: Cycle 1: 2023-03-23 (Score: 16), Cycle 2: 2021-06-10 (Score: 24), Cycle 3: 2019-03-01 (Score: 24)
Total Weighted Health Score: 20.000
Reported Incidents: 0, Substantiated Complaints: 0
Infection Control Citations:
Fines and Penalties: Number of Fines: 2, Total Fines in Dollars: 5650.00, Payment Denials Number: 0, Total Penalties Number: 2
Location and GPS: 1404 N LAFAYETTE STREET,SHELBY,NC,28150 (35.3177, -81.538)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-30
Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-30
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-30
Type: Health, Deficiency: Ensure each resident receives an accurate assessment.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-07-16
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-07-16
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-07-16
Type: Health, Deficiency: Assure that each resident’s assessment is updated at least once every 3 months.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-22
Type: Health, Deficiency: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-22
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-22
Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-22
Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-22
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0917, Version: New
Description: Ensure electrical receptacles or cover plates have distinctive color or marking.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-05
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-03
Type: Fire Safety, Tag: 0521, Version: New
Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-03
Type: Fire Safety, Tag: 0761, Version: New
Description: To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-03
Type: Fire Safety, Tag: 0001, Version: New
Description: Establish an Emergency Preparedness Program (EP).
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-22