Cycle 1
Health 2024-08-21 · Fire 2024-08-21
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Carthage, NC
Peak Resources - Pinelake
4-star overall rating with 4-star inspections with $7,901 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
801 Pinehurst Avenue, Carthage, NC
(910) 947-5155
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
108
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
1992-12-14
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
0.41
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.88
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
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,407
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9975
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.18
Baseline 24.11% · Performance 18.67% · Measure score 7.18 · Achievement 5.95 · Improvement 7.18
Healthcare-associated infections
5.51
Baseline 7.33% · Performance 6.19% · Measure score 5.51 · Achievement 5.51 · Improvement 4.40
Total nurse turnover
5.09
Baseline 56.41% · Performance 42.86% · Measure score 5.09 · Achievement 5.09 · Improvement 3.79
Adjusted total nurse staffing
0
Baseline 3.12 hours · Performance 3.06 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.74% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 143 · Observed rate 9.09% · Lower 95% interval 7.06% |
| Discharge to community | 48.07% |
50.57%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 135 · Observed rate 38.52% · Lower 95% interval 38.31% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.98% |
95.27%
3.7 pts better
|
Numerator 97 · Denominator 98 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 2 · Denominator 98 |
| Discharge self-care score | 47.3% |
53.69%
6.4 pts worse
|
Numerator 35 · Denominator 74 |
| Discharge mobility score | 36.49% |
50.94%
14.4 pts worse
|
Numerator 27 · Denominator 74 |
| Pressure ulcers or injuries, new or worsened | 6.12% |
2.29%
3.8 pts worse
|
Numerator 6 · Denominator 98 · Adjusted rate 6.12% |
| Healthcare-associated infections requiring hospitalization | 6.19% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 5.88% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 82 |
| Staff flu vaccination coverage | 34.12% |
42%
7.9 pts worse
|
Numerator 29 · Denominator 85 |
| Discharge function score | 44.59% |
56.45%
11.9 pts worse
|
Numerator 33 · Denominator 74 |
| Transfer of health information to provider | 95.45% |
95.95%
0.5 pts worse
|
Numerator 21 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 38 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 44.9% |
25.2%
19.7 pts better
|
Numerator 22 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 1.7 · 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 98.8% · Q2 100.0% · 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 | 3.7% |
3.6%
0.1 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.8% · Q3 5.0% · Q4 3.9% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.2% |
4.8%
4.4 pts worse
|
11.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 7.6% · Q3 10.3% · Q4 12.5% · 4Q avg 9.2% |
| Percentage of long-stay residents who lose too much weight | 10.1% |
7.2%
2.9 pts worse
|
5.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 11.0% · Q3 9.9% · Q4 9.9% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.3% |
21.6%
7.3 pts better
|
19.6%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 11.8% · Q3 12.2% · Q4 18.1% · 4Q avg 14.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.9% |
15.0%
3.1 pts better
|
16.7%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 8.6% · Q3 10.8% · Q4 8.5% · 4Q avg 11.9% · 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 | 13.4% |
21.5%
8.1 pts better
|
16.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 3.8% · Q3 16.1% · Q4 9.3% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.2% |
16.8%
2.4 pts worse
|
14.9%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 20.3% · Q3 18.2% · Q4 12.3% · 4Q avg 19.2% · 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 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
2.6%
1 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.6% · Q3 2.6% · Q4 3.9% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.3% |
21.2%
7.9 pts better
|
19.8%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 10.3% · Q3 12.7% · Q4 10.1% · 4Q avg 13.3% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
6.0%
3 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.1% · Q3 0.9% · Q4 5.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
79.9%
12.3 pts better
|
81.7%
10.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.6% · Q2 90.1% · Q3 93.5% · Q4 93.1% · 4Q avg 92.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
13.2%
5.9 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 7.3% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.1%
21.9 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
22.9%
5.5 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 25.6% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-22 · Fire 2022-09-22
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-08-21
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 2024-10-01
F · Potential for more than minimal harm
2022-09-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-27
F · Potential for more than minimal harm
2022-09-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-27
F · Potential for more than minimal harm
2022-09-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-27
F · Potential for more than minimal harm
2022-09-22
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-09-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-09-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-09-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-25
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.
Not marked corrected
D · Potential for more than minimal harm
2024-08-21
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-08-28
B · Minimal harm
2024-08-21
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-09-06
G · Actual harm
2023-11-30
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 2023-07-21
B · Minimal harm
2023-11-30
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 2023-12-15
B · Minimal harm
2023-11-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-15
B · Minimal harm
2023-11-30
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 2023-12-15
B · Minimal harm
2023-11-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-12-15
E · Potential for more than minimal harm
2022-09-22
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-22
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 2022-10-14
E · Potential for more than minimal harm
2022-09-22
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-22
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-14
C · Minimal harm
2022-09-22
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-09-23
B · Minimal harm
2022-09-22
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-10-14
B · Minimal harm
2022-09-22
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 2022-10-14
Penalties and ownership
What sits behind the stars
$7,901
2023-11-30
Fine
Fine · fine $7,901
Fine
Ownership
Hill, Brian
Operational/Managerial Control · Individual
Peak Resources Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
The Greens at Pinehurst Rehabilitation & Living Ce
Pinehurst, NC
3-star overall rating with 3-star inspections with $41,844 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Saint Joseph of the Pines Health Center
Pinehurst, NC
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Penick Village
Southern Pines, NC
5-star overall rating with 4-star inspections with $14,940 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out