Cycle 1
Health 2024-10-31 · Fire 2024-10-31
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Graham, NC
Peak Resources - Alamance, Inc
5-star overall rating with 5-star inspections with $3,728 in total fines with 1 fire-safety deficiencies in the latest cycle
215 College Street, Graham, NC
(336) 228-8394
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
142
Certified beds
Average residents
132
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Peak Resources, Inc.
Operator or chain grouping
Approved since
1990-11-08
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
0.30
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.19
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.86
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,115
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.77
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.05
Baseline 20.92% · Performance 19.09% · Measure score 5.05 · Achievement 5.05 · Improvement 4.20
Healthcare-associated infections
1.99
Baseline 6.24% · Performance 7.24% · Measure score 1.99 · Achievement 1.99 · Improvement 0
Total nurse turnover
2.94
Baseline 66.67% · Performance 52.29% · Measure score 2.94 · Achievement 2.79 · Improvement 2.94
Adjusted total nurse staffing
1.13
Baseline 3.2 hours · Performance 3.40 hours · Measure score 1.13 · Achievement 1.13 · Improvement 0.27
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.76% |
10.72%
3 pts worse
|
No Different than the National Rate · Eligible stays 202 · Observed rate 15.35% · Lower 95% interval 10.11% |
| Discharge to community | 51.13% |
50.57%
0.6 pts better
|
No Different than the National Rate · Eligible stays 211 · Observed rate 46.45% · Lower 95% interval 44.58% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 70.68% |
95.27%
24.6 pts worse
|
Numerator 94 · Denominator 133 |
| Falls with major injury | 1.5% |
0.77%
0.7 pts worse
|
Numerator 2 · Denominator 133 |
| Discharge self-care score | 51.52% |
53.69%
2.2 pts worse
|
Numerator 34 · Denominator 66 |
| Discharge mobility score | 69.7% |
50.94%
18.8 pts better
|
Numerator 46 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 3.76% |
2.29%
1.5 pts worse
|
Numerator 5 · Denominator 133 · Adjusted rate 3.82% |
| Healthcare-associated infections requiring hospitalization | 7.24% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 111 · Observed rate 8.11% · Lower 95% interval 4.47% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 97 |
| Staff flu vaccination coverage | 20.34% |
42%
21.7 pts worse
|
Numerator 24 · Denominator 118 |
| Discharge function score | 53.03% |
56.45%
3.4 pts worse
|
Numerator 35 · Denominator 66 |
| Transfer of health information to provider | 93.75% |
95.95%
2.2 pts worse
|
Numerator 30 · Denominator 32 |
| Transfer of health information to patient | 95.06% |
96.28%
1.2 pts worse
|
Numerator 77 · Denominator 81 |
| Resident COVID-19 vaccinations up to date | 53.03% |
25.2%
27.8 pts better
|
Numerator 35 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
1.8
1.3 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 4.4 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.2 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
91.5%
7.4 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 98.9% · Q3 100.0% · Q4 99.0% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
94.1%
3.9 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.6%
0.1 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 1.1% · Q3 3.4% · Q4 4.1% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
4.8%
4.5 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 10.5% |
7.2%
3.3 pts worse
|
5.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 12.2% · Q3 15.4% · Q4 7.9% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
21.6%
4.9 pts better
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 18.3% · Q3 17.3% · Q4 15.6% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.2% |
15.0%
12.2 pts worse
|
16.7%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 29.2% · Q3 27.5% · Q4 26.6% · 4Q avg 27.2% · 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 | 21.8% |
21.5%
0.3 pts worse
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 21.8% · Q3 19.1% · Q4 34.0% · 4Q avg 21.8% · 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 8.5% · Q2 11.0% · Q3 11.1% · Q4 25.8% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.1% |
2.6%
1.5 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.4% · Q3 4.5% · Q4 3.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.1% |
21.2%
8.1 pts better
|
19.8%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 16.2% · Q3 8.5% · Q4 5.8% · 4Q avg 13.1% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
6.0%
1.5 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 9.9% · Q3 4.7% · Q4 6.1% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
79.9%
19 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 98.9% · Q3 99.2% · Q4 99.2% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
13.2%
About the same
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 14.0% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 0.0% · Q4 0.7% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.3% |
78.1%
17.2 pts better
|
79.7%
15.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.8% |
22.9%
5.1 pts better
|
23.9%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 20.2% · Expected 26.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-11 · Fire 2023-08-11
4 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-04-21 · Fire 2022-04-21
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-10-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-11
D · Potential for more than minimal harm
2023-08-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-04-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-04-24
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-26
D · Potential for more than minimal harm
2023-09-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-02
E · Potential for more than minimal harm
2023-08-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-19
D · Potential for more than minimal harm
2023-08-11
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-09-19
Penalties and ownership
What sits behind the stars
$3,728
2023-08-11
Fine
Fine · fine $3,728
Fine
Ownership
Hill, Brian
Operational/Managerial Control · Individual
Hill, Brian
Corporate Officer · Individual
Peak Resources Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Alamance Health Care Center
Burlington, NC
2-star overall rating with 2-star inspections with $157,560 in total fines with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
White Oak Manor - Burlington
Burlington, NC
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $148,522 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Edgewood Place at the Village at Brookwood
Burlington, NC
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out