Hillsborough, NC

Peak Resources - Brookshire, Inc

3-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

300 Meadowlands Drive, Hillsborough, NC

(919) 644-6714

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

80

Certified beds

Average residents

75

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Peak Resources, Inc.

Operator or chain grouping

Approved since

1993-06-23

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.52

Registered nurse staffing

LPN hours / resident day

1.07

Licensed practical nurse staffing

Aide hours / resident day

1.96

Nurse aide staffing

Weekend hours

3.22

Weekend nurse staffing

RN turnover

18%

Annual RN turnover

Total nurse turnover

44%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.0
1.8
0.2 pts worse
1.9
0.1 pts worse
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 1.5
1.8
0.3 pts better
1.8
0.3 pts better
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 79.3%
91.5%
12.2 pts worse
93.4%
14.1 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 93.2%
94.1%
0.9 pts worse
95.5%
2.3 pts worse
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 7.0%
3.6%
3.4 pts worse
3.3%
3.7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 0.4%
4.8%
4.4 pts better
11.4%
11 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 11.5%
7.2%
4.3 pts worse
5.4%
6.1 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 14.0%
21.6%
7.6 pts better
19.6%
5.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 14.2%
15.0%
0.8 pts better
16.7%
2.5 pts better
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened 1.9%
21.5%
19.6 pts better
16.3%
14.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 5.9%
16.8%
10.9 pts better
14.9%
9 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
0.9%
0.9 pts better
1.0%
1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 0.4%
2.6%
2.2 pts better
1.7%
1.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 17.8%
21.2%
3.4 pts better
19.8%
2 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 9.8%
6.0%
3.8 pts worse
5.1%
4.7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 88.0%
79.9%
8.1 pts better
81.7%
6.3 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 16.2%
13.2%
3 pts worse
12.0%
4.2 pts worse
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 0.8%
1.5%
0.7 pts better
1.6%
0.8 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 88.0%
78.1%
9.9 pts better
79.7%
8.3 pts better
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 22.4%
22.9%
0.5 pts better
23.9%
1.5 pts better
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-28 · Fire 2025-02-28

7 health deficiencies

Top issue: Resident Rights (4 deficiencies)

2 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 2 Health 2023-10-27 · Fire 2023-10-27

5 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2022-04-07 · Fire 2022-04-07

6 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

5 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-02-28

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2025-03-28

D · Potential for more than minimal harm 2025-02-28

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-03-28

F · Potential for more than minimal harm 2023-10-27

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2024-01-05

E · Potential for more than minimal harm 2023-10-27

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2024-01-05

E · Potential for more than minimal harm 2023-10-27

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-01-05

E · Potential for more than minimal harm 2023-10-27

K900 · Miscellaneous Deficiencies

Fire Safety

Meet Health Care Facilities Code mechanical requirements.

Corrected 2024-01-05

E · Potential for more than minimal harm 2023-10-27

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2024-01-05

D · Potential for more than minimal harm 2023-10-27

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 2024-01-05

D · Potential for more than minimal harm 2023-10-27

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-01-05

D · Potential for more than minimal harm 2023-10-27

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-01-05

D · Potential for more than minimal harm 2023-10-27

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-01-05

F · Potential for more than minimal harm 2022-04-07

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2022-05-27

F · Potential for more than minimal harm 2022-04-07

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2022-05-27

F · Potential for more than minimal harm 2022-04-07

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2022-06-16

D · Potential for more than minimal harm 2022-04-07

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2022-05-27

D · Potential for more than minimal harm 2022-04-07

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-05-27

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-02-28

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.

Corrected 2025-03-25

D · Potential for more than minimal harm 2025-02-28

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2025-01-28

D · Potential for more than minimal harm 2025-02-28

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2025-03-25

D · Potential for more than minimal harm 2025-02-28

F626 · Resident Rights Deficiencies

Health

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Corrected 2025-03-25

D · Potential for more than minimal harm 2025-02-28

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-03-24

D · Potential for more than minimal harm 2025-02-28

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2025-03-25

D · Potential for more than minimal harm 2025-02-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-27

D · Potential for more than minimal harm 2024-03-16

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-03-08

E · Potential for more than minimal harm 2023-10-27

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-11-30

E · Potential for more than minimal harm 2023-10-27

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2023-11-30

D · Potential for more than minimal harm 2023-10-27

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2023-11-30

D · Potential for more than minimal harm 2023-10-27

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2023-11-30

F · Potential for more than minimal harm 2022-04-07

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 2022-04-29

E · Potential for more than minimal harm 2022-04-07

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 2022-04-29

E · Potential for more than minimal harm 2022-04-07

F809 · Nutrition and Dietary Deficiencies

Health

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Corrected 2022-04-29

E · Potential for more than minimal harm 2022-04-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-04-29

D · Potential for more than minimal harm 2022-04-07

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2022-04-29

D · Potential for more than minimal harm 2022-04-07

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-04-29

Penalties and ownership

What sits behind the stars

Ownership

Harold P Nunn Tr

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2023-05-01
Hill, Brian

Operational/Managerial Control · Individual

0% 10 facilities 2022-09-01
Hill, Brian

Corporate Officer · Individual

0% 10 facilities 2022-09-01
Miller, June

Operational/Managerial Control · Individual

0% 2 facilities 2022-01-01
Peak Resources Inc

Operational/Managerial Control · Organization

0% 9 facilities 2019-08-01
Reutter, Amanda

Operational/Managerial Control · Individual

0% 1 facilities 2022-02-01

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