Peak Resources - Alamance, Inc

Based on observations and staff interviews, the facility failed to discard expired medications stored in 1 of 2 medication storerooms (Station 1 Medication Storeroom), store medications in accordance with the manufacturer's instructions in 1 of 2 medication storerooms (Station 1 Medication Storeroom), and date medications as to when they were opened to allow for the determination of the shortened expiration date in 1 of 2 medication storerooms (Station 3 Medication Storeroom).The findings included:1. An observation was conducted on 3/4/26 at 11:15 AM of the Station 1 Medication Storeroom. The observation revealed the following medications were stored in the medication storeroom:a. An unopened box of Allegra D (an over-the-counter antihistamine and decongestant) containing 15 tablets was stored on the shelf of the medication storeroom. The manufacturer's expiration date of November 2025 was printed on the box containing the tablets, indicating this medication was expired.b. An opened box containing six (6) 14 milligram (mg) Nicotine Transdermal System Patches was stored on the shelf…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with home health, resident, and staff, the facility failed to implement an effective discharge planning process that ensured the resident was referred for home health services prior to discharge to the community to ensure services were not delayed for 1 of 3 residents (Resident #148) reviewed for discharge.The findings included:Resident #148 was most recently readmitted to the facility on [DATE] with diagnoses that included a displaced fracture of the second right metatarsal bone [a break in the second metatarsal (the longest metatarsal or bone in the foot] where the bone fragments are misaligned), cerebral palsy (a brain disorder that permanently affects body movement and muscle coordination), and muscle weakness.A review of Resident 148's Care Plan dated 01/10/2025 revealed no information related to discharge planning.The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #148 was cognitively intact. Her Activities of Daily Living abilities were as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of urinary catheter (Resident #157) and medications (Resident #64) for 2 of 29 residents whose MDS assessments were reviewed . The findings included: 1. Resident #157 was admitted to the facility on [DATE] with diagnoses which included flaccid neuropathic (underactive) bladder. Review of the physician orders for Resident #157 revealed an order dated 7/6/25 for an indwelling urinary catheter and to provide urinary catheter care every shift. Review of the physician orders, dated 8/13/25, revealed an order for Resident #157 to discontinue use of the indwelling urinary catheter. Review of the physician orders, dated 8/13/25, revealed an order for Resident #157 to use intermittent urinary catheter as needed. Review of Resident #157's July and August 2025 Medication Administration Records (MAR) revealed nurses documented urinary catheter care every shift from 7/6/25 through 8/13/25.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to prevent a fall from a mechanical lift for one (Resident #1) of three residents reviewed for supervision to prevent accidents. Findings included: Resident #1 was admitted on [DATE] with multiple diagnoses some of which included a birth defect resulting in a cognitive and developmental disability and spinal stenosis. Documentation in a nutrition note dated 2/20/2024 revealed Resident #1 was 5 feet tall and weighed 193 pounds. Documentation in a nursing progress note for Resident #1 dated 2/20/2024 at 3:20 PM revealed, Writer notified by [Medication Aide] that resident was on floor. The Writer immediately assessed resident for injury. Resident denies pain. No [signs or symptoms] of pain. PACE (Program of All-Inclusive Care for the Elderly) notified, and order received by the Doctor. Transferred to [Emergency Room]. Resident was not moved until EMS (emergency medical services) arrived and EMS transferred resident via [mechanical lift] from floor to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview the facility's Quality Assessment Performance Improvement committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the complaint investigation completed 9/19/2023. This was a repeat deficiency in the area of supervision to prevent accidents that was originally cited on 9/19/2023. The continued failure of the facility with a repeat deficiency showed a pattern of the facility's inability to sustain an effective Quality Assessment Performance Improvement program. The findings included: This citation is cross referred to: F689: During the complaint investigation of 4/24/2024 the facility failed to prevent a fall from a mechanical lift for one of three residents reviewed for supervision to prevent accidents. During the complaint investigation of 09/19/2023 the facility failed to provide incontinent care safely for one of three residents reviewed for accidents. The Administrator was interviewed on 4/24/2024 at 11:07 AM. The Administrator stated the Quality Assessment Performance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and Nurse Practitioner interviews, the facility failed to provide incontinent care safely for 1 of 3 residents reviewed for accidents (Resident #1). During incontinent care provided by Nurse Aide (NA) #1, Resident #1 rolled off the bed and landed on her knees with no injuries. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses which included vascular dementia with behavioral disturbance and difficulty in walking. A physician order dated 08/19/23 indicated Resident #1 was prescribed Apixaban (a medication to prevent blood clots) 2.5 milligrams twice a day for atrial fibrillation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had moderate cognitive impairment, required extensive assistance of one with bed mobility, toilet use, and personal hygiene. Resident #1 was coded as not having behavioral symptoms or refusal of care. The MDS indicated the resident was always incontinent of bowel and bladder.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and record review the facility failed to: 1) keep the floors of the walk-in refrigerator and walk-in freezer clean; 2) label foods in the walk-in refrigerator, reach-in refrigerator and in three of three nourishment room refrigerators; 3) ensure the food in walk-in freezer was free of ice; 4) ensure the divided plates used for the upcoming meal were clean; 5) utilize clean dollies to store cups and glasses; and 6) ensure male dietary staff (dietary cook, dietary aide #2 and # 3) had all facial hair contained in a face covering. These practices had the potential to affect food being served to residents. Finding included: 1a) An observation of the walk-in refrigerator on 8/7/23 at 6:12 AM revealed light brown colored crust on the floor under the racks containing milk. [NAME] colored fluid was observed on the floor. There were pieces of brown paper and plastic cling wrap on the floor. The floor was dirty and sticky. During an interview on 8/7/23 at 6:15 AM, the Dietary Aide #1 stated she was unsure what the brown colored crust was. She further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours a day for 1 out of 121 days reviewed for staffing (2/4/2023). Findings included: The daily assignment sheets were reviewed from January1, 2023 through March 31,2023 and July 7, 2023, through August 8, 2023, it revealed that on 2/4/23 there was no RN assigned to work in the facility. Record review of the daily nurse staffing hours from February 1 to February 28, 2023 revealed that 8 RN hours were assigned on 2/4/23; this did not match the daily assignment sheet provided. An interview and record review of the 2/4/23 staff assignment sheet and the daily nursing department staffing form with the Director of Nursing (DON) on 08/09/23 at 2:56 PM revealed that a RN was documented on the daily staffing hours and there was no RN assigned on the staff assignment sheet. She stated in the past the scheduler was responsible to confirm an RN was assigned 8 hours each day. There was currently no scheduler, and she was responsible for nursing staff assignments. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.