Cycle 1
Health 2025-04-03 · Fire 2025-04-03
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Gastonia, NC
Peak Resources - Gastonia
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2780 X-Ray Drive, Gastonia, NC
(704) 861-0981
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Peak Resources, Inc.
Operator or chain grouping
Approved since
1999-06-30
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
0.50
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.36
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.94
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.30
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,458
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.73
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.61% · Performance 21.52% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.69% · Performance 12.03% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.6
Baseline 46.15% · Performance 40.79% · Measure score 5.6 · Achievement 5.6 · Improvement 2.02
Adjusted total nurse staffing
1.09
Baseline 3.21 hours · Performance 3.39 hours · Measure score 1.09 · Achievement 1.09 · Improvement 0.18
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.89% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 157 · Observed rate 17.83% · Lower 95% interval 9.82% |
| Discharge to community | 59.59% |
50.57%
9 pts better
|
No Different than the National Rate · Eligible stays 128 · Observed rate 53.13% · Lower 95% interval 49.15% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.03% |
95.27%
1.2 pts worse
|
Numerator 63 · Denominator 67 |
| Falls with major injury | 1.52% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 66 |
| Discharge self-care score | 54% |
53.69%
0.3 pts better
|
Numerator 27 · Denominator 50 |
| Discharge mobility score | 52% |
50.94%
1.1 pts better
|
Numerator 26 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 3.08% |
2.29%
0.8 pts worse
|
Numerator 2 · Denominator 65 · Adjusted rate 2.37% |
| Healthcare-associated infections requiring hospitalization | 12.03% |
7.12%
4.9 pts worse
|
Worse than the National Rate · Eligible stays 85 · Observed rate 18.82% · Lower 95% interval 8.27% |
| Staff COVID-19 vaccination coverage | 0.89% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 112 |
| Staff flu vaccination coverage | 27.91% |
42%
14.1 pts worse
|
Numerator 24 · Denominator 86 |
| Discharge function score | 62% |
56.45%
5.5 pts better
|
Numerator 31 · Denominator 50 |
| 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 | 97.14% |
96.28%
0.9 pts better
|
Numerator 34 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 29.03% |
25.2%
3.8 pts better
|
Numerator 9 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.1 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.8
1 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
91.5%
7.9 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.8% · Q3 98.8% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
94.1%
4.8 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.6%
0.8 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.7% · Q3 2.5% · Q4 1.3% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.8%
4.8 pts better
|
11.4%
11.4 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 who lose too much weight | 6.9% |
7.2%
0.3 pts better
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 9.1% · Q3 5.6% · Q4 7.4% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.4% |
21.6%
5.8 pts worse
|
19.6%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 28.2% · Q3 26.4% · Q4 25.0% · 4Q avg 27.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
15.0%
0.2 pts worse
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 17.1% · Q3 17.2% · Q4 10.0% · 4Q avg 15.2% · 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 | 12.5% |
21.5%
9 pts better
|
16.3%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.9% |
16.8%
12.9 pts better
|
14.9%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 2.7% · Q3 0.0% · Q4 3.0% · 4Q avg 3.9% · 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 | 1.0% |
2.6%
1.6 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.9% |
21.2%
8.3 pts better
|
19.8%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 11.1% · Q3 7.4% · Q4 17.2% · 4Q avg 12.9% |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
6.0%
5.1 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 1.0% · Q4 1.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
79.9%
16 pts better
|
81.7%
14.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 99.1% · Q3 94.8% · Q4 92.4% · 4Q avg 95.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.0% |
13.2%
10.2 pts better
|
12.0%
9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.0% · Observed 2.9% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
78.1%
16.5 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.6% |
22.9%
11.3 pts better
|
23.9%
12.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 11.6% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-06-09 · Fire 2022-06-09
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-04-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-06-15
D · Potential for more than minimal harm
2022-06-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-06-09
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-03
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 2025-04-21
D · Potential for more than minimal harm
2025-04-03
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 2025-04-21
E · Potential for more than minimal harm
2023-12-14
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 2024-01-09
D · Potential for more than minimal harm
2023-12-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-09
D · Potential for more than minimal harm
2022-06-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-06-28
D · Potential for more than minimal harm
2022-06-09
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-06-28
Penalties and ownership
What sits behind the stars
Ownership
Hill, Brian
Operational/Managerial Control · Individual
Hill, Brian
Corporate Officer · Individual
Peak Resources Inc
Operational/Managerial Control · Organization
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#3
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