Cleveland House

Overview of Cleveland House

Cleveland House is a 72-bed home for the aged facility at 950 Hardin Drive, Shelby, Cleveland County, North Carolina. It provides 24-hour staffing and accepts Medicaid, focusing on residential senior care.

Serious resident care failures and systemic fire safety infrastructure deficiencies characterize Cleveland House’s regulatory record. Over six years, the facility averaged 10 deficiencies annually, 92 percent above North Carolina’s 5.2-deficiency benchmark. A substantiated January 2020 complaint investigation documented critical care failures during a norovirus outbreak. The facility failed to maintain temperature at 75°F in resident rooms and dining area during winter.

One of five staff members sampled had substantiated findings on the North Carolina Health Care Personnel Registry upon hire. Personal care failures resulted in untreated genital and buttock rash and dried soiled incontinent brief adhered to skin for two of five residents. Timely referral and follow-up failed for residents with untreated rash and psychotropic medication not administered for up to 28 days. Medications were improperly labeled for two residents; four residents did not receive medications as ordered (9.5 percent medication error rate).

Medication administration records were inaccurate for two residents. The facility failed to notify Cleveland County Department of Social Services of incidents resulting in injury or emergency medical evaluation for six of 26 residents involving falls. Residents were denied showers and personal care during outbreak. Infection control policy was not implemented per CDC guidelines.

A substantiated November 2019 complaint investigation identified four resident care deficiencies. The facility failed to provide adequate supervision for five sampled residents related to falls. Failed to assure timely referral and follow-up for acute health care needs. Failed to treat residents with dignity and respect.

Failed to notify local law enforcement of a resident’s unexpected death.

Physical plant and fire safety failures appear across inspection cycles.

June 2019 construction survey identified 10 deficiencies. Earlier inspections spanning 2015-2017 document persistent fire safety infrastructure failures including unprotected penetrations in smoke barriers, missing or damaged sprinkler heads, non-functioning emergency lighting, improperly stored portable oxygen cylinders, inadequate fire safety rehearsal documentation, electrical hazards, and non-functioning exhaust fans in multiple locations. Follow-up surveys in 2015 and 2017 confirmed some deficiencies remained uncorrected.

Medication administration deficiencies appear across clinical inspections. November 2022 annual survey documented failure to ensure physician contact for unclear medication order for one resident and inaccurate electronic medication administration records for wound care documentation. No fines or license suspensions appear in the record.

The pattern of serious resident care failures during the 2020 norovirus outbreak, combined with persistent fire safety and physical plant deficiencies, warrants careful family inquiry.

Families should ask about corrections following the January 2020 outbreak, fire safety, fall-risk supervision, and medication administration oversight and electronic record accuracy procedures.

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