Peak Resources- Shelby
Peak Resources- Shelby in Grover, NC — inspection on February 11, 2026.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
(injury/decline/room, etc.) that affect the resident.
record review, and staff and Physician Assistant interviews, the facility failed to notify the
resident reviewed for notification (Resident #75).The findings included:Resident #75 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes.Resident #75's physician orders and medication administration record (MAR) revealed the following: On 11/25/25 a physician order was written for semaglutide (0.25 mg or 0.50 mg) to be administered subcutaneously once a week on Mondays.The MAR indicated it was administered on 12/01/25 at 8:00 AM (Nurse #2), was not administered on 12/08/25 due to the resident refused (Nurse #2) and was not administered on 12/15/25 due to awaiting delivery from the pharmacy (Nurse #2). On 12/22/25 semaglutide (0.25 mg or 0.50 mg) was discontinued. A review of Resident #75's medical record revealed there was no documentation indicating the Physician/Physician Assistant had been notified that semaglutide was not administered as ordered.An interview conducted with Nurse #2 on 2/09/26 at 2:04 PM revealed she was assigned to Resident #75 on first shift (7:00 AM to 7:00 PM).
Nurse #2 indicated Resident #75 had an order for semaglutide, but it was not available in the medication room on 12/01/25 or 12/08/25 or 12/15/25 and she did not administer the medication.
Nurse #2 stated she documented on the MAR in error that she administered the semaglutide on 12/01/25 and that Resident #75 refused the medication on 12/08/25 and she should have documented the medication was not administered because it was unavailable.
Nurse #2 indicated she notified the provider when a resident did not receive a prescribed medication, however she did not recall if she notified the Physician Assistant that Resident #75 had not received the semaglutide. An interview conducted with the Physician Assistant on 2/11/26 at 1:25 PM revealed she gave a new order on 11/25/25 for Resident #75 to start semaglutide 0.25 mg to help regulate her blood sugars and assist with weight loss.
The Physician Assistant stated she entered the order in the electronic medical record (EMR) and notified Nurse #1 the order was ready to be sent to the pharmacy.
The Physician Assistant stated she was not notified that the order sent to the pharmacy did not have the dose of the medication or that the medication was not delivered until 12/29/25.
The Physician Assistant revealed there were no adverse outcomes from Resident #75 not receiving the semaglutide starting in November however the facility should have notified her that Resident #75 was not receiving the medication. An interview conducted with the Administrator on 2/11/26 at 3:42 PM revealed the Physician/Physician Assistant should be notified when a resident was not receiving a prescribed medication whether the medication was unavailable or the resident refused to take the medication.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
345229 02/11/2026
Peak Resources- Shelby 726 South Battleground Ave Grover, NC 28073
During a phone interview with the Medical Director on 2/11/26 at 1:14 PM he revealed the Physician Assistant did consult him regarding Resident #75's weight gain and varying blood sugars and he agreed with starting semaglutide.
The Medical Director stated Resident #75 not receiving the semaglutide would not have caused an adverse outcome however resident medications should be administered as ordered.An interview conducted with the Administrator on 2/11/26 at 3:42 PM when the pharmacy notified the Former DON the order sent for Resident #75 to start semaglutide did not include the dosage information, she should have clarified the order with the Physician Assistant and sent the updated order to the pharmacy.
The Administrator indicated medications should be obtained from the pharmacy and administered to the residents as ordered by the physician.
345229 02/11/2026
Peak Resources- Shelby 726 South Battleground Ave Grover, NC 28073
consent from the Responsible Party.
The DON indicated she expected all residents to receive podiatry
he come to her and voiced concerns regarding his toenails hurting or difficulty ambulating.
The
to be seen by the podiatrist.
The Administrator indicated she expected all residents to receive podiatry services when needed and Resident #63 would be receiving services moving forward.
345229 02/11/2026
Peak Resources- Shelby 726 South Battleground Ave Grover, NC 28073
aware.
The Administrator indicated when a medication was not available the assigned nurse, Nurse#1
ordered by the physician.
345229 02/11/2026
Peak Resources- Shelby 726 South Battleground Ave Grover, NC 28073
professional principles; and all drugs and biologicals must be stored in locked compartments,
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on
medication stored in 1 of 1 medication room refrigerator reviewed for medication storage (Medication room [ROOM NUMBER])The findings included:An observation of Medication room [ROOM NUMBER] was conducted on 2/9/2026 at 11:52 AM in the presence of Medication Aide (MA) #1.
The following medication was found in the medication room refrigerator in a locked bin: one vial of Lorazepam 2 mg/ml (milligrams/ milliliter).
The expiration date on the vial was August 2025 and was not opened.
MA #1 confirmed the expiration date by reading aloud the date printed on the vial.An interview with the MA #1 was completed on 2/9/2026 at 11:53 AM. MA #1 stated that she was not sure who would check the medication room for expired medications and thought it was a night shift staff member that checked the temperature for the refrigerator. MA #1 reported that the Pharmacist would check the medication room monthly but would need to confirm with the Director of Nursing (DON).The interview conducted with the DON on 2/11/2026 at 2:50 PM revealed that the Pharmacist visits the facility once per month to check for expired medications.
The DON reported once a medication was discontinued the nurse should have removed the medication from the cart or refrigerator and placed the medication in pharmacy container for medications to be returned to the pharmacy.An interview was completed with the Administrator on 2/11/2026 at 3:30 PM.
The Administrator stated that expired medication should be sent back to pharmacy.
The Administrator reported that each nurse should check medication orders each shift and send back discontinued medication to the pharmacy.
The Administrator stated that she expected staff to check carts for expired and discontinued medications prior to dispensing medications to residents.A phone interview was completed with the Pharmacist on 02/11/2026 at 4:47 PM.
The Pharmacist stated that he visits the facility once a month to complete medication administration observations with medication aides and nurses.
The Pharmacist also reported that he had a team member that would visit the facility every other month to check the medication room for expiredmedications and medications that required more stock.
The Pharmacist stated that he would check the medication in the medication carts during the medication administration observations for expired medications.
The Pharmacist stated that the facility should not rely on pharmacy visits to review medication stock for expired medication because his team may not check the medication stock every month.
345229 02/11/2026
Peak Resources- Shelby 726 South Battleground Ave Grover, NC 28073
During a phone interview with the Pharmacist on 2/11/26 at 1:48 PM he revealed the facility sent an order on 11/25/25 for Resident #75 to start semaglutide but the order did not include the dosage information.
The Pharmacist revealed the facility sent a new order on for semaglutide 0.25 mg and the medication was delivered to the facility on [DATE].
Several attempts made to contact the Former DON were unsuccessful. An interview conducted with the Administrator on 2/11/26 at 3:42 PM revealed she was not aware that Resident #75 was not administered semaglutide as ordered because it was not delivered by the pharmacy and unavailable.
The Administrator stated when a medication was not administered it should be documented accurately in the resident record and on the MAR.
345229 02/11/2026
Peak Resources- Shelby 726 South Battleground Ave Grover, NC 28073
and hand hygiene.