Cycle 1
Health 2025-06-26 · Fire 2024-03-21
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Charlotte, NC
Peak Resources - Charlotte
3-star overall rating with 3-star inspections with $14,069 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3223 Central Avenue, Charlotte, NC
(704) 749-1100
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
123
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Peak Resources, Inc.
Operator or chain grouping
Approved since
1968-06-01
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
0.18
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.09
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
2.89
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.08
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.19
CMS adjusted RN staffing hours
Adjusted total hours
3.28
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,561
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.26
Baseline 20.04% · Performance 18.99% · Measure score 5.26 · Achievement 5.26 · Improvement 2.98
Healthcare-associated infections
2.24
Baseline 6.48% · Performance 7.17% · Measure score 2.24 · Achievement 2.24 · Improvement 0
Total nurse turnover
3.46
Baseline 53.76% · Performance 49.54% · Measure score 3.46 · Achievement 3.46 · Improvement 0.96
Adjusted total nurse staffing
0.81
Baseline 2.97 hours · Performance 3.31 hours · Measure score 0.81 · Achievement 0.81 · Improvement 0.72
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.66% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 12.5% · Lower 95% interval 7.41% |
| Discharge to community | 47.53% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 37.21% · Lower 95% interval 36.16% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 0% |
95.27%
95.3 pts worse
|
Numerator 0 · Denominator 21 |
| Falls with major injury | 4.76% |
0.77%
4 pts worse
|
Numerator 1 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 9.52% |
2.29%
7.2 pts worse
|
Numerator 2 · Denominator 21 · Adjusted rate 8.95% |
| Healthcare-associated infections requiring hospitalization | 7.16% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 25 · Observed rate 8% · Lower 95% interval 4.13% |
| Staff COVID-19 vaccination coverage | 20% |
8.2%
11.8 pts better
|
Numerator 27 · Denominator 135 |
| Staff flu vaccination coverage | 35% |
42%
7 pts worse
|
Numerator 49 · Denominator 140 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.9 · 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 1.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
91.5%
4.1 pts better
|
93.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 92.5% · Q3 98.1% · Q4 99.1% · 4Q avg 95.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
94.1%
5 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.6%
2.5 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 2.8% · Q3 0.9% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.7% |
4.8%
0.9 pts worse
|
11.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 6.4% · Q3 4.1% · Q4 3.9% · 4Q avg 5.7% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
7.2%
2.3 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.5% · Q3 12.9% · Q4 13.5% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.7% |
21.6%
2.1 pts worse
|
19.6%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 22.9% · Q3 25.3% · Q4 25.7% · 4Q avg 23.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.8% |
15.0%
9.2 pts better
|
16.7%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.4% · Q3 6.2% · Q4 4.5% · 4Q avg 5.8% · 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 | 11.5% |
21.5%
10 pts better
|
16.3%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 9.3% · Q3 16.6% · Q4 10.7% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
16.8%
7.5 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 17.4% · Q3 8.3% · Q4 6.2% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
2.6%
1.7 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.2% |
21.2%
3 pts better
|
19.8%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 26.9% · Q3 11.7% · Q4 14.6% · 4Q avg 18.2% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
6.0%
1.4 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.7% · Q3 10.0% · Q4 7.7% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.4% |
79.9%
8.5 pts better
|
81.7%
6.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.9% · Q2 84.6% · Q3 89.2% · Q4 88.3% · 4Q avg 88.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.0% |
13.2%
6.8 pts worse
|
12.0%
8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 20.8% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.3% |
78.1%
9.2 pts better
|
79.7%
7.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
22.9%
1.4 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 25.0% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2022-09-29
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-09-29 · Fire 2021-05-28
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-03-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-03
D · Potential for more than minimal harm
2022-09-29
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 2022-11-25
D · Potential for more than minimal harm
2022-09-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-25
D · Potential for more than minimal harm
2022-09-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-25
D · Potential for more than minimal harm
2021-05-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-05-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-06-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-26
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 2025-07-13
D · Potential for more than minimal harm
2025-06-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-13
J · Immediate jeopardy
2024-03-21
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 2023-06-17
E · Potential for more than minimal harm
2024-03-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-21
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 2024-04-19
E · Potential for more than minimal harm
2024-03-21
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-21
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-21
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 2024-04-19
D · Potential for more than minimal harm
2024-03-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-21
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 2024-04-19
G · Actual harm
2023-03-22
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-03-20
G · Actual harm
2023-03-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-03-20
G · Actual harm
2023-03-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-20
F · Potential for more than minimal harm
2022-09-29
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-11-11
E · Potential for more than minimal harm
2022-09-29
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-09-29
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 2022-11-11
D · Potential for more than minimal harm
2022-09-29
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 2022-11-11
D · Potential for more than minimal harm
2022-09-29
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.
Corrected 2022-11-11
Penalties and ownership
What sits behind the stars
$14,069
2024-03-21
Fine
Fine · fine $14,069
Fine
Ownership
Hill, Brian
Operational/Managerial Control · Individual
Nunn, Deborah
Corporate Director · Individual
Peak Resources Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Pelican Health at Charlotte
Charlotte, NC
1-star overall rating with 1-star inspections with $70,925 in total fines with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Accordius Health at Midwood, LLC
Charlotte, NC
2-star overall rating with 1-star inspections with $144,199 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Asbury Health and Rehabilitation Center
Charlotte, NC
2-star overall rating with 2-star inspections with $53,176 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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