Cycle 1
Health 2026-02-11 · Fire 2024-11-21
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Shelby, NC
Peak Resources- Shelby
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1101 North Morgan Street, Shelby, NC
(704) 482-5396
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Peak Resources, Inc.
Operator or chain grouping
Approved since
1982-10-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 4 overall / 4 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.30
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.80
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.37
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,777
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9867
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.70
Baseline 20.96% · Performance 20.64% · Measure score 1.70 · Achievement 1.70 · Improvement 0.31
Healthcare-associated infections
2.66
Baseline 6.37% · Performance 7.04% · Measure score 2.66 · Achievement 2.66 · Improvement 0
Total nurse turnover
6.89
Baseline 56.06% · Performance 35.53% · Measure score 6.89 · Achievement 6.89 · Improvement 6.08
Adjusted total nurse staffing
1.45
Baseline 3.08 hours · Performance 3.49 hours · Measure score 1.45 · Achievement 1.45 · Improvement 1.01
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.01% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 123 · Observed rate 13.01% · Lower 95% interval 8.25% |
| Discharge to community | 58.34% |
50.57%
7.8 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 52.08% · Lower 95% interval 49.37% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 85.71% |
95.27%
9.6 pts worse
|
Numerator 66 · Denominator 77 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 77 |
| Discharge self-care score | 63.04% |
53.69%
9.4 pts better
|
Numerator 29 · Denominator 46 |
| Discharge mobility score | 36.96% |
50.94%
14 pts worse
|
Numerator 17 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 5.19% |
2.29%
2.9 pts worse
|
Numerator 4 · Denominator 77 · Adjusted rate 4.38% |
| Healthcare-associated infections requiring hospitalization | 7.04% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 7.69% · Lower 95% interval 4.76% |
| Staff COVID-19 vaccination coverage | 1.11% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 90 |
| Staff flu vaccination coverage | 38.32% |
42%
3.7 pts worse
|
Numerator 41 · Denominator 107 |
| Discharge function score | 39.13% |
56.45%
17.3 pts worse
|
Numerator 18 · Denominator 46 |
| Transfer of health information to provider | 95.83% |
95.95%
0.1 pts worse
|
Numerator 23 · Denominator 24 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 17.95% |
25.2%
7.2 pts worse
|
Numerator 7 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.2 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
1.8
1.2 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 3.2 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
91.5%
7.6 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.3% · Q4 98.2% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.2% |
3.6%
4.6 pts worse
|
3.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 7.0% · Q3 12.1% · Q4 10.7% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
4.8%
0.4 pts worse
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 6.0% · Q3 5.6% · Q4 1.9% · 4Q avg 5.2% |
| Percentage of long-stay residents who lose too much weight | 12.6% |
7.2%
5.4 pts worse
|
5.4%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 18.0% · Q3 9.3% · Q4 12.7% · 4Q avg 12.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.7% |
21.6%
10.1 pts worse
|
19.6%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 31.5% · Q3 26.8% · Q4 30.9% · 4Q avg 31.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.5% |
15.0%
6.5 pts worse
|
16.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 20.5% · Q3 21.7% · Q4 30.6% · 4Q avg 21.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.8% |
21.5%
9.7 pts better
|
16.3%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.4% |
16.8%
2.4 pts better
|
14.9%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 16.7% · Q3 8.0% · Q4 21.3% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 1.1% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.6%
1.3 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.1% |
21.2%
3.1 pts better
|
19.8%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 16.5% · Q3 14.9% · Q4 21.5% · 4Q avg 18.1% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
6.0%
1.4 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 1.8% · Q3 6.4% · Q4 3.3% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
79.9%
12.8 pts better
|
81.7%
11 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.1% · Q2 91.9% · Q3 95.6% · Q4 91.7% · 4Q avg 92.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.7% |
13.2%
5.5 pts worse
|
12.0%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 18.6% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.5%
1.2 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 1.4% · Q3 0.0% · Q4 5.6% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.6% |
78.1%
6.5 pts better
|
79.7%
4.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.2% |
22.9%
3.7 pts better
|
23.9%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 21.4% · Expected 26.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-21 · Fire 2023-10-11
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-10-11 · Fire 2023-04-06
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-07
D · Potential for more than minimal harm
2023-10-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-10-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-04-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-02-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Not marked corrected
D · Potential for more than minimal harm
2026-02-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Not marked corrected
D · Potential for more than minimal harm
2026-02-11
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Not marked corrected
D · Potential for more than minimal harm
2026-02-11
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Not marked corrected
D · Potential for more than minimal harm
2026-02-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Not marked corrected
D · Potential for more than minimal harm
2026-02-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Not marked corrected
D · Potential for more than minimal harm
2026-02-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
E · Potential for more than minimal harm
2024-11-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-11-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-11
D · Potential for more than minimal harm
2023-10-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-27
Penalties and ownership
What sits behind the stars
Ownership
Deborah Jean Nunn Mrtl Tr - 2023
5% Or Greater Direct Ownership Interest · Organization
Century Care Of Shelby
5% Or Greater Direct Ownership Interest · Organization
Deborah Jean Nunn Mrtl Tr - 2023
Operational/Managerial Control · Organization
Hainsworth, Jeffrey
Corporate Director · Individual
Hill, Brian
Corporate Officer · Individual
Nunn, Harold
5% Or Greater Direct Ownership Interest · Individual
Peak Resources Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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White Oak Manor-Shelby
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2-star overall rating with 2-star inspections with $42,637 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Cleveland Pines
Shelby, NC
3-star overall rating with 3-star inspections with $5,000 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Carolina Care Health and Rehabilitation
Cherryville, NC
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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