Peak Resources- Shelby: Foot Care Deficiencies - NC
The resident, identified in inspection records only as Resident #75, was admitted to the facility with type 2 diabetes. On November 25, 2025, her physician assistant ordered semaglutide, a medication prescribed to regulate her blood sugars and help with weight loss. The order went to the pharmacy the same day.
It never came back correctly filled.
The pharmacist, reached by phone during the February inspection, said the facility's original order was missing dosage information. A corrected order was sent, and the medication was eventually delivered, but the pharmacist did not specify when. Resident #75, who is cognitively intact according to her quarterly assessment, told inspectors on February 9 that the drug was not administered to her until January 2026, roughly six weeks after it was ordered.
What the medical record showed during that gap was something else entirely.
Nurse #2, who was assigned to Resident #75 on the day shift, documented on the Medication Administration Record that she gave the resident semaglutide on December 1 at 8:00 a.m. She documented on December 8 that the resident refused it. She documented on December 15 that it was awaiting pharmacy delivery.
When inspectors interviewed Nurse #2 on February 9, she told them the medication was not available on any of those three dates and was not administered on any of them. She said she documented the December 1 administration in error and that she should have noted the medication was unavailable, not that she had given it. She acknowledged the December 8 refusal notation was also wrong.
The administrator told inspectors she had no idea Resident #75 had gone without the medication because it was never delivered. She said that when a medication is not given, it should be documented accurately. The inspection report notes that attempts to reach the former director of nursing were unsuccessful.
What the record showed and what actually happened to Resident #75 were two different things for at least three consecutive weeks, and possibly longer. A resident who was cognitively intact and aware enough to track her own care told inspectors she waited until January to receive a medication her doctor ordered in November.
Inspectors rated the violation as causing minimal harm or potential for actual harm, the lower end of the federal harm scale. Semaglutide is prescribed for blood sugar regulation in type 2 diabetics, and a six-week gap in its administration is a gap in the management of a chronic condition. Whether Resident #75's blood sugars were affected during those weeks, the inspection report does not say.
What it does say is that the nurse responsible for her care wrote down that she gave a drug she didn't have, wrote down that the resident refused a drug that wasn't there, and that no one in a supervisory role caught it. The administrator learned the truth not from her own staff or her own records, but from federal inspectors.
Resident #75 spent November and December waiting for a medication she'd been told she was getting.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Peak Resources- Shelby from 2026-02-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
Peak Resources- Shelby in Grover, NC was cited for violations during a health inspection on February 11, 2026.
The resident, identified in inspection records only as Resident #75, was admitted to the facility with type 2 diabetes.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.