Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Peak Resources- Shelby during CMS and state inspections, most recent first.
A resident with type 2 DM had a new weekly semaglutide order entered into the EMR, but the drug was not available on multiple scheduled administration dates and was not actually given. An RN documented on the MAR that the dose was administered on one date and refused on another, later acknowledging these entries were incorrect and that the medication had been unavailable. There was no documentation that the MD/PA was notified that the ordered semaglutide was not being administered, and the PA reported she was unaware the medication had not been delivered or given until weeks later. The Administrator confirmed that providers are to be notified whenever a resident does not receive a prescribed medication, regardless of unavailability or refusal.
A resident with type 2 DM, weight gain, and varying blood sugars was started on weekly semaglutide by a PA after consultation with the medical director, but the order sent to the pharmacy lacked a specific dose. The pharmacist repeatedly notified the former DON that the order required clarification before the drug could be dispensed, yet no corrected order with dosage was provided until a new order specifying 0.25 mg was entered weeks later. During this period, nursing staff documented the drug as given or refused on the MAR despite it being unavailable on multiple dates, and the unit manager was unaware that the pharmacy needed clarification. The resident reported that the medication, intended to help regulate blood sugars and assist with weight loss, was not actually administered until weeks after it was first ordered.
A resident with CAD, HTN, DM, and prior CVA, who had moderately impaired cognition but was independent with dressing, footwear, and hygiene, was not provided appropriate foot care or podiatry services despite having thick, overgrown toenails causing pain with walking and shoe wear. A nurse conducting a weekly skin assessment noticed the long toenails but did not document the finding or initiate a podiatry referral because the resident had not complained. The resident was not placed on the podiatry schedule, and no podiatry consults were documented. NAs, who provided only set-up assistance for bathing and allowed the resident to dress and apply socks independently, reported they had not seen the toenails and had not been told of discomfort. Later observations by nursing staff and the wound nurse confirmed the toenails were excessively long and required podiatry trimming.
A resident with type 2 DM and recent significant weight gain was started on semaglutide once weekly, but the order entered into the EMR contained incomplete dosage information, and the verifying nurse sent it to the pharmacy without correction. The pharmacist reported multiple unsuccessful attempts by phone, fax, and email to obtain clarification so the drug could be dispensed, while nursing staff noted the medication was not available in the med room and assumed it had not yet been delivered, without contacting the pharmacy or consistently notifying the provider. As a result, the ordered semaglutide was not supplied or administered as intended, and the order was later discontinued.
Surveyors found an unopened vial of Lorazepam 2 mg/mL past its expiration date stored in a locked bin in a medication room refrigerator. A medication aide confirmed the expiration date and reported uncertainty about who is responsible for checking the room for expired meds, believing night shift staff only monitor refrigerator temperatures and that the Pharmacist visits monthly. The DON stated the Pharmacist checks for expired meds monthly and that nurses are expected to remove discontinued meds and place them in pharmacy return containers. The Administrator reported that nurses should review medication orders each shift, send back discontinued meds, and check carts for expired and discontinued meds before administration. The Pharmacist indicated he conducts monthly med pass observations, a team member checks the medication room every other month for expired meds and stock, and that the facility should not rely solely on pharmacy visits to identify expired medications.
A resident with type 2 DM had an order for weekly subcutaneous semaglutide to help regulate blood sugars and assist with weight loss, but the drug was not available for multiple scheduled doses. An RN documented on the MAR that the medication was administered on one date and refused on another, even though she later stated the medication was not available and was not given on those dates. The resident, who was cognitively intact, reported that the medication was not actually started until a later month. The pharmacist indicated the initial order lacked dosage information and that semaglutide was delivered only after a corrected order was received, while the Administrator stated she was unaware the medication had not been administered and that non-administration should be documented accurately.
A Treatment Nurse failed to follow the facility’s infection control policy requiring glove changes and hand hygiene between dirty and clean steps of wound care for three residents with pressure ulcers and surgical wounds. For each resident, the nurse cleaned the wound with gauze and wound cleanser, then, without changing gloves or performing hand hygiene, proceeded to apply topical agents, dressings, and wraps. The nurse later acknowledged awareness of the required glove-change and hand hygiene steps but stated she became nervous while being observed. The IP and DON both confirmed that the nurse should have changed gloves and performed hand hygiene between wound cleansing and application of clean dressings.
A resident receiving insulin injections twice daily was not having her blood sugar levels monitored due to a lapse in communication and order entry in the eMAR. The Nurse Practitioner discontinued the sliding scale insulin but did not intend to stop FSBS checks. Staff were unaware of the discontinuation, and the facility lacked a policy for FSBS use in diabetics.
A survey of a medication cart revealed deficiencies in insulin pen labeling and storage. Opened Glargine and Novolog insulin pens were undated, and Insulin detemir and Lispro pens were expired. An unopened insulin pen was improperly stored outside the refrigerator. Interviews with a nurse and the DON confirmed these issues, indicating lapses in medication management protocols.
Failure to Notify Provider When Ordered Medication Not Administered
Penalty
Summary
The deficiency involves the facility’s failure to notify the Physician/Physician Assistant when a resident did not receive a prescribed medication. A resident admitted with type 2 diabetes had an order written on 11/25/25 for weekly subcutaneous semaglutide (0.25 mg or 0.50 mg) on Mondays. The MAR showed the medication as administered on 12/01/25 at 8:00 AM, refused by the resident on 12/08/25, and not administered on 12/15/25 due to awaiting delivery from the pharmacy, with the order discontinued on 12/22/25. Review of the medical record revealed no documentation that the Physician/Physician Assistant had been notified that the semaglutide was not administered as ordered. During interview, the nurse assigned to the resident stated the semaglutide was not available in the medication room on 12/01/25, 12/08/25, or 12/15/25 and that she did not administer the medication on those dates. She acknowledged documenting in error on the MAR that the medication was given on 12/01/25 and that the resident refused it on 12/08/25, and stated she should have documented that the medication was unavailable. She reported that she generally notified providers when a resident did not receive a prescribed medication but could not recall notifying the Physician Assistant in this case. The Physician Assistant reported entering the semaglutide order in the EMR on 11/25/25 and notifying a nurse that it was ready to be sent to the pharmacy, and stated she was not informed that the order sent lacked a dose or that the medication was not delivered until 12/29/25. The Administrator stated that the Physician/Physician Assistant should be notified whenever a resident is not receiving a prescribed medication, whether due to unavailability or refusal.
Failure to Clarify Semaglutide Order and Obtain Medication as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a new medication order for semaglutide was clarified and processed so the medication could be obtained and administered as ordered. A physician assistant evaluated Resident #75, who had type 2 diabetes, weight gain of approximately 15 pounds in three months, and varying blood sugars, and entered an order on 11/25/25 for semaglutide to be given weekly. The order in the physician orders and MAR was written as semaglutide (0.25 mg or 0.50 mg) weekly, and the MAR showed an entry that it was administered on 12/01/25, refused on 12/08/25, and unavailable on 12/15/25, with discontinuation on 12/22/25 and a new order on 12/29/25 for semaglutide 0.25 mg weekly. The resident’s MDS documented that she was cognitively intact, had an active diagnosis of diabetes mellitus, and was receiving insulin injections daily, and her care plan identified risk for hypo- and hyperglycemic episodes with monitoring interventions. Resident #75 reported that semaglutide was ordered in late November to help regulate blood sugars and assist with weight loss but was not actually administered until January, and she did not question the delay because she believed it usually took a while for the facility to obtain new medications. She confirmed refusing the first two January doses because she had questions for the physician assistant about possible reactions, and stated that the medication was administered as ordered later in January. Nurse #2, who was assigned to the resident on day shift, stated that semaglutide was not available on three December dates and therefore was not administered, and she could not recall whether she notified the unit manager or provider about the unavailability. She further acknowledged that she documented in error on the MAR that the medication was administered on one date and refused on another, and that she should have documented that the medication was unavailable. Nurse #1, the unit manager, explained that new medication orders are entered into the EMR, verified, and sent electronically to the pharmacy, and that she verified the semaglutide order and sent it to the pharmacy but was not aware that the dose was missing or that clarification was needed. The pharmacist reported that the facility sent an order for semaglutide without dosage information and that the former DON was notified on four separate dates that the order needed to be resent with the dose before the medication could be dispensed and delivered. The pharmacist stated that a new order specifying semaglutide 0.25 mg weekly was finally sent on 12/29/25 and the medication was delivered on 12/31/25. The physician assistant and medical director both stated they were not informed that the pharmacy required clarification or that the resident had not received semaglutide until mid-January, and both stated that medications should be administered as ordered. The administrator stated that when the pharmacy notified the former DON that the order lacked dosage information, the former DON should have clarified the order with the physician assistant and sent an updated order to the pharmacy so the medication could be obtained and administered as ordered.
Failure to Assess and Arrange Podiatry Care for Long, Painful Toenails
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and arrange podiatry services for a resident with multiple medical conditions, including CAD, hypertension, diabetes mellitus, and a history of CVA. The resident’s care plan, revised on 12/07/25, identified the need for extensive and total staff assistance with ADLs, including grooming and personal hygiene, while also noting that the resident ambulated independently with a cane. A quarterly MDS documented that the resident had moderately impaired cognition but was independent with dressing, footwear, personal hygiene, and ambulation with a walker, and did not reject care. Despite these assessments, the resident’s weekly skin assessment dated 02/05/26, completed by Nurse #1, contained no notation that the toenails were long, thick, or required trimming or podiatry referral, even though Nurse #1 later acknowledged she had noticed the long toenails at that time but did not document them because the resident had not complained. Further record review showed the resident was not on the February 2026 podiatry clinic schedule, and there were no podiatry consultation reports or notes from admission through 02/11/26. During an observation and interview on 02/08/26, the resident removed his socks and displayed thick, long toenails on the left foot extending past the nail bed, reporting pain when putting on shoes and walking, and stating he had not reported this because he did not want to bother staff, although he believed staff had seen them. Subsequent observations with Nurse #1 and the Wound Care Nurse confirmed the toenails were long, thick, and in need of podiatry trimming, with the left hallux nail curved to the side and measured lengths up to 3 cm. Nursing assistants reported they had not seen the resident’s toenails because he dressed himself, wore his socks, and preferred to bathe in his room with only set-up assistance, and he had not voiced discomfort to them. The DON stated that NAs should have alerted nurses and that nurses should have assessed toenails during weekly skin assessments and placed the resident on the podiatry list when needed, while the Administrator reported she had not been informed of the issue and that the resident had not approached her with concerns.
Failure to Clarify and Obtain Ordered Diabetic Medication From Pharmacy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a complete and clear prescription for a new diabetic medication and to respond to repeated pharmacy requests for clarification, resulting in the medication not being dispensed. A resident with type 2 diabetes, weight gain of approximately 15 pounds over three months, and noncompliance with a diabetic diet was evaluated by a Physician Assistant, who ordered semaglutide 0.25 mg once weekly to help regulate blood sugars and assist with weight loss. The physician order entered on 11/25/25 in the EMR read semaglutide (0.25 mg or 0.50 mg) to be administered subcutaneously once a week on Mondays, which the pharmacist later identified as lacking complete dosage information. The order was verified and sent to the pharmacy by the unit manager nurse on 11/28/25 without recognizing the incomplete dosage. The MAR showed one administration documented in error, one refusal, and one missed dose due to awaiting pharmacy delivery, and the order was discontinued on 12/22/25. Nursing staff did not ensure the medication was available or follow up appropriately when it was not in the medication room. The nurse assigned to the resident on the relevant dates reported that semaglutide was not available and that she assumed the new medication had not yet been delivered; she did not call the pharmacy to check the status and did not recall notifying the Physician Assistant, though she stated the unit manager nurse was aware. The unit manager nurse stated she believed the medication was not delivered because it was unavailable and did not follow up with the pharmacy. The pharmacist reported that the pharmacy attempted to contact the facility multiple times by phone, fax, and email on four separate dates to obtain clarification of the semaglutide order so it could be dispensed, but the facility did not provide a corrected order until 12/29/25. The Administrator stated she did not receive the pharmacy’s emails and could not confirm whether the former DON had received or acted on them, while also indicating that when a medication is not available, the assigned nurse, unit manager, and/or DON should contact the pharmacy or send a refill request in the EMR to ensure medications are available and administered as ordered.
Expired Lorazepam Vial Found in Medication Room Refrigerator
Penalty
Summary
Surveyors identified a deficiency in medication storage and monitoring when an unopened vial of Lorazepam 2 mg/mL with an expiration date of August 2025 was found in a locked bin in medication room [ROOM NUMBER]'s refrigerator. The observation occurred in the presence of a medication aide, who verified the expiration date on the vial. The report does not identify any specific resident associated with this medication or any clinical use at the time of the survey. During interviews, the medication aide stated she was unsure who was responsible for checking the medication room for expired medications and believed night shift staff only checked the refrigerator temperature. She also indicated that the Pharmacist visited monthly but needed to confirm details with the DON. The DON reported that the Pharmacist visits once per month to check for expired medications and that nurses are expected to remove discontinued medications from carts or the refrigerator and place them in pharmacy return containers. The Administrator stated that expired medications should be sent back to the pharmacy and that each nurse should check medication orders each shift and remove discontinued medications, as well as check carts for expired and discontinued medications before administering medications. The Pharmacist reported that he visits monthly for medication administration observations and that a team member visits every other month to check the medication room for expired medications and stock needs, and further stated that the facility should not rely on pharmacy visits to review medication stock for expired medications because pharmacy staff may not check the stock every month.
Inaccurate MAR Documentation for Ordered Semaglutide Therapy
Penalty
Summary
The facility failed to maintain accurate medication administration records for a resident with type 2 diabetes who had an order for semaglutide. Physician orders and the MAR showed an order dated 11/25/25 for semaglutide (0.25 mg or 0.50 mg) to be given subcutaneously once weekly on Mondays. The MAR reflected that semaglutide was administered on 12/01/25 at 8:00 AM, was refused by the resident on 12/08/25, and was not given on 12/15/25 due to awaiting delivery from the pharmacy, all documented by the same nurse. However, the resident, who was assessed as cognitively intact on a quarterly MDS, reported that although the PA ordered semaglutide on 11/25/25 to help regulate blood sugars and assist with weight loss, the medication was not actually administered until January 2026. In an interview, the nurse assigned to the resident on day shift stated that semaglutide was not available on 12/01/25, 12/08/25, or 12/15/25 and was not administered on those dates. She acknowledged that her MAR entries indicating administration on 12/01/25 and refusal on 12/08/25 were erroneous and that she should have documented the medication as unavailable. The pharmacist reported that the original order sent on 11/25/25 lacked dosage information, and a new order specifying semaglutide 0.25 mg was later sent, after which the medication was delivered. The Administrator stated she was not aware that the resident had not received semaglutide as ordered because it was not delivered and unavailable, and confirmed that when a medication is not administered it should be documented accurately in the resident record and on the MAR.
Failure to Follow Hand Hygiene and Glove-Change Protocol During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policy during wound care for three residents. The facility’s policy, revised on 10/28/24, required staff to perform hand hygiene before and after donning gloves, to change gloves when moving from dirty to clean tasks, and to always change gloves between residents. During wound care for Resident #4, the Treatment Nurse was observed with a gown already on, sanitized her hands, and donned clean gloves. The dressing had already come off earlier during incontinence care. She cleaned the coccyx pressure ulcer with gauze soaked in wound cleaner and, without changing gloves or performing hand hygiene, applied Santyl ointment, wet-to-moist Dakin’s solution, packed the wound bed, and applied a super absorbent pad before discarding supplies and removing PPE. During wound care for Resident #62, the Treatment Nurse donned a clean gown and gloves, removed the old dressing from the resident’s right ankle, and cleaned the wound with gauze soaked in wound cleaner. While still wearing the same gloves used for cleaning, she applied an axeroform petrolatum dressing to the wound. She then collected and discarded the supplies, removed her gown and gloves, and washed her hands with soap and water only after the entire procedure was completed, without an interim glove change or hand hygiene between the dirty and clean portions of the wound care. For Resident #103, the Treatment Nurse entered the room wearing a gown, washed her hands, and put on gloves before removing the dressing from a right heel pressure ulcer. She then removed her gloves, used hand sanitizer, donned new gloves, and cleaned the ulcer with gauze soaked in wound cleaner. Without removing gloves or performing hand hygiene, she patted the ulcer dry with gauze, applied collagenase ointment with a cotton swab, covered the wound with calcium alginate and an abdominal pad, and wrapped the foot. After removing gloves and using hand sanitizer, she donned new gloves and removed the dressing from a surgical wound with staples on the resident’s left foot, then again removed gloves, sanitized her hands, and applied new gloves before cleaning the wound. She proceeded to cover the left foot wound with an abdominal pad and wrap it with gauze without changing gloves or performing hand hygiene between cleaning and dressing application. In interviews, the Treatment Nurse, Infection Preventionist, and DON all acknowledged that gloves should have been changed and hand hygiene performed between cleaning the wounds and applying clean dressings for all three residents.
Failure to Monitor Blood Sugar Levels in Insulin-Dependent Resident
Penalty
Summary
The facility failed to monitor a resident's blood sugar levels despite the resident receiving insulin injections twice daily. The resident, who was cognitively intact and required substantial assistance for most activities of daily living, expressed concern that her blood sugar was no longer being checked. She received 14 units of insulin in the morning and 16 units in the evening, but the staff had stopped checking her blood sugar, leading to episodes of increased sleepiness. The issue arose when the Nurse Practitioner discontinued the resident's sliding scale insulin order but did not intend for the finger-stick blood sugar (FSBS) checks to be discontinued. However, the FSBS checks were inadvertently stopped due to the way orders were entered into the electronic Medication Administration Record (eMAR). The facility's staff, including nurses and the consulting pharmacist, were unaware that the FSBS checks had been discontinued, and the resident's blood sugar levels had not been monitored since the sliding scale insulin order was discontinued. Interviews with the facility's staff revealed a lack of awareness and communication regarding the discontinuation of FSBS checks. The Director of Nursing and the Administrator were also unaware of the lapse in monitoring. The facility did not have a policy regarding FSBS use for diabetics, and the Medical Director mentioned that residents were assessed on a case-by-case basis for FSBS orders, with some consideration being given to using HbA1c levels for monitoring instead.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols for insulin pens, as observed during a survey of the Hall A medication cart. Specifically, the survey revealed that opened Glargine and Novolog insulin pens were not dated, and an opened Insulin detemir flexpen and Lispro insulin pen were past their expiration dates based on the open dates of 08/23/2024 and 09/24/2024, respectively. Additionally, an unopened insulin pen was improperly stored in the medication cart instead of the refrigerator, contrary to the manufacturer's instructions. Interviews with Nurse #1 and the Director of Nursing (DON) confirmed the deficiencies. Nurse #1 acknowledged the oversight in dating the insulin pens and the presence of expired pens. The DON reiterated that all insulin pens should be labeled with an open date and a 28-day expiration date, and that unopened pens should be refrigerated. The DON also stated that it was the responsibility of all nurses to check for expired medications in the carts, highlighting a lapse in the facility's medication management practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Grover
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| White Oak Manor-kings Mountain | 5.8 mi | ★★★★★ | 13 | 1 |
| White Oak Manor-shelby | 10.5 mi | ★★★★★ | 6 | 0 |
| Cleveland Pines | 11.5 mi | ★★★★★ | 7 | 0 |
| Belaire Health Care Center | 12.8 mi | ★★★★★ | 1 | 0 |
| Peachtree Centre | 13.7 mi | ★★★★★ | 8 | 0 |
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