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)
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
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
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
0.52
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.07
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
3.55
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.29
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
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,207
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9938
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.83
Baseline 19.95% · Performance 20.58% · Measure score 1.83 · Achievement 1.83 · Improvement 0
Healthcare-associated infections
8.04
Baseline 6.00% · Performance 5.43% · Measure score 8.04 · Achievement 8.04 · Improvement 5.18
Total nurse turnover
3.77
Baseline 50.67% · Performance 48.28% · Measure score 3.77 · Achievement 3.77 · Improvement 0.43
Adjusted total nurse staffing
2.72
Baseline 3.57 hours · Performance 3.85 hours · Measure score 2.72 · Achievement 2.72 · Improvement 0.79
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.38% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 150 · Observed rate 9.33% · Lower 95% interval 7.08% |
| Discharge to community | 58.94% |
50.57%
8.4 pts better
|
Better than the National Rate · Eligible stays 128 · Observed rate 53.91% · Lower 95% interval 52.62% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 78.57% |
95.27%
16.7 pts worse
|
Numerator 66 · Denominator 84 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 84 |
| Discharge self-care score | 59.7% |
53.69%
6 pts better
|
Numerator 40 · Denominator 67 |
| Discharge mobility score | 65.67% |
50.94%
14.7 pts better
|
Numerator 44 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 1.19% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 84 · Adjusted rate 1.03% |
| Healthcare-associated infections requiring hospitalization | 5.43% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 93 · Observed rate 2.15% · Lower 95% interval 3.22% |
| Staff COVID-19 vaccination coverage | 2.26% |
8.2%
5.9 pts worse
|
Numerator 3 · Denominator 133 |
| Staff flu vaccination coverage | 13.85% |
42%
28.1 pts worse
|
Numerator 18 · Denominator 130 |
| Discharge function score | 65.67% |
56.45%
9.2 pts better
|
Numerator 44 · Denominator 67 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 43 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 23.4% |
25.2%
1.8 pts worse
|
Numerator 11 · Denominator 47 |
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 · Adjusted 2.0 · Observed 2.2 · Expected 2.1 · Used in QM five-star |
| 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 · Adjusted 1.5 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| 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 · Q1 46.0% · Q2 73.5% · Q3 98.4% · Q4 100.0% · 4Q avg 79.3% |
| 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 · 4Q avg 93.2% |
| 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 · Q1 4.8% · Q2 5.9% · Q3 9.5% · Q4 8.1% · 4Q avg 7.0% · Used in QM five-star |
| 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 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| 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 · Q1 10.9% · Q2 14.8% · Q3 10.9% · Q4 8.9% · 4Q avg 11.5% |
| 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 · Q1 10.9% · Q2 9.8% · Q3 16.1% · Q4 19.6% · 4Q avg 14.0% |
| 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 · Q1 12.8% · Q2 10.6% · Q3 14.9% · Q4 18.4% · 4Q avg 14.2% · 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 | 1.9% |
21.5%
19.6 pts better
|
16.3%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.9% · Used in QM five-star |
| 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 · Q1 9.3% · Q2 12.1% · Q3 1.8% · Q4 0.0% · 4Q avg 5.9% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| 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 · Q1 14.1% · Q2 18.8% · Q3 22.4% · Q4 16.0% · 4Q avg 17.8% |
| 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 · Q1 9.3% · Q2 14.9% · Q3 11.7% · Q4 2.7% · 4Q avg 9.8% · Used in QM five-star |
| 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 · Q1 81.9% · Q2 82.2% · Q3 93.6% · Q4 93.9% · 4Q avg 88.0% |
| 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 · Adjusted 16.2% · Observed 15.9% · Expected 11.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.6% · Q3 1.4% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| 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 · 4Q avg 88.0% |
| 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 · Adjusted 22.4% · Observed 22.7% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
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
Hill, Brian
Operational/Managerial Control · Individual
Hill, Brian
Corporate Officer · Individual
Miller, June
Operational/Managerial Control · Individual
Peak Resources Inc
Operational/Managerial Control · Organization
Reutter, Amanda
Operational/Managerial Control · Individual
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