Cycle 1
Health 2025-03-07 · Fire 2025-03-07
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wilmington, NC
Peak Resources-Wilmington, Inc
1-star overall rating with 2-star inspections with abuse icon flag with $35,483 in total fines with 7 recent health deficiencies
2305 Silver Stream Lane, Wilmington, NC
(910) 362-3621
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Peak Resources, Inc.
Operator or chain grouping
Approved since
2005-09-30
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
0.35
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.91
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,981
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.59% · Performance 22.61% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.92% · Performance 9.42% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.02
Baseline 34.72% · Performance 47.25% · Measure score 4.02 · Achievement 4.02 · Improvement 0
Adjusted total nurse staffing
1.76
Baseline 3.60 hours · Performance 3.58 hours · Measure score 1.76 · Achievement 1.76 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.3% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 140 · Observed rate 9.29% · Lower 95% interval 7.45% |
| Discharge to community | 56.39% |
50.57%
5.8 pts better
|
No Different than the National Rate · Eligible stays 122 · Observed rate 51.64% · Lower 95% interval 45.91% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 88.89% |
95.27%
6.4 pts worse
|
Numerator 32 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 15 · Denominator 30 |
| Discharge mobility score | 26.67% |
50.94%
24.3 pts worse
|
Numerator 8 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 2.78% |
2.29%
0.5 pts worse
|
Numerator 1 · Denominator 36 · Adjusted rate 2.37% |
| Healthcare-associated infections requiring hospitalization | 9.42% |
7.12%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 14.29% · Lower 95% interval 5.94% |
| Staff COVID-19 vaccination coverage | 1.87% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 107 |
| Staff flu vaccination coverage | 11.72% |
42%
30.3 pts worse
|
Numerator 15 · Denominator 128 |
| Discharge function score | 36.67% |
56.45%
19.8 pts worse
|
Numerator 11 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · 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 | 2.4 |
1.8
0.6 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
91.5%
7.1 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 100.0% · Q3 100.0% · Q4 98.8% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.9% |
94.1%
1.8 pts better
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.6%
0.4 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.3% · Q3 3.6% · Q4 3.5% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.6% |
4.8%
0.2 pts better
|
11.4%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.8% · Q3 7.0% · Q4 6.8% · 4Q avg 4.6% |
| 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 8.8% · Q2 16.0% · Q3 8.5% · Q4 6.7% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.5% |
21.6%
3.9 pts worse
|
19.6%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 30.1% · Q3 23.0% · Q4 22.8% · 4Q avg 25.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.7% |
15.0%
2.7 pts worse
|
16.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 19.1% · Q3 13.6% · Q4 16.7% · 4Q avg 17.7% · 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 | 28.4% |
21.5%
6.9 pts worse
|
16.3%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 21.1% · 4Q avg 28.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.5% |
16.8%
7.7 pts worse
|
14.9%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 27.3% · Q3 28.4% · Q4 18.1% · 4Q avg 24.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
2.6%
0.5 pts better
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.2% · Q3 2.5% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.6% |
21.2%
2.6 pts better
|
19.8%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 25.8% · Q3 17.5% · Q4 16.3% · 4Q avg 18.6% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
6.0%
0.6 pts better
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 8.7% · Q3 3.4% · Q4 2.4% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.7% |
79.9%
7.8 pts better
|
81.7%
6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 79.4% · Q2 100.0% · Q3 95.7% · Q4 75.6% · 4Q avg 87.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
13.2%
1.5 pts better
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 11.9% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.2% |
1.5%
4.7 pts worse
|
1.6%
4.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.1% |
78.1%
19 pts better
|
79.7%
17.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
22.9%
7.3 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 33.3% · Expected 26.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-12 · Fire 2024-01-12
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-08-18 · Fire 2022-08-18
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-01-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-01-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-12
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 2024-03-08
D · Potential for more than minimal harm
2024-01-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-08
F · Potential for more than minimal harm
2022-08-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-11-02
F · Potential for more than minimal harm
2022-08-18
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-11-02
D · Potential for more than minimal harm
2022-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-07
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 2025-04-04
D · Potential for more than minimal harm
2025-03-07
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 2025-03-30
D · Potential for more than minimal harm
2025-03-07
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 2025-04-03
D · Potential for more than minimal harm
2025-03-07
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 2025-04-03
D · Potential for more than minimal harm
2025-03-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-07
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-04-04
B · Minimal harm
2025-03-07
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-03-30
D · Potential for more than minimal harm
2024-09-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-02-29
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 2024-03-01
D · Potential for more than minimal harm
2024-02-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-01
G · Actual harm
2024-01-12
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 2024-02-29
F · Potential for more than minimal harm
2024-01-12
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 2024-02-29
F · Potential for more than minimal harm
2024-01-12
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-01-12
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 2024-02-29
E · Potential for more than minimal harm
2024-01-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-01-12
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-01-12
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-12
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-12
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-29
B · Minimal harm
2024-01-12
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 2024-02-12
B · Minimal harm
2024-01-12
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 2024-02-12
Penalties and ownership
What sits behind the stars
$35,483
2024-01-12
Fine
Fine · fine $35,483
Fine
$0
2024-01-12
Payment Denial
Payment Denial · denial start 2024-02-13 · 17 days
17 day denial
Ownership
Deborah Jean Nunn Mrtl Tr - 2023
5% Or Greater Direct Ownership Interest · Organization
Hill, Brian
Operational/Managerial Control · Individual
Hill, Brian
Corporate Officer · Individual
Peak Resources Inc
Operational/Managerial Control · Organization
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