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Peak Resources - Brookshire, Inc Inspection Report, Violations & Safety Grade (Hillsborough, North Carolina)

300 Meadowlands Drive, Hillsborough, North Carolina 27278

Phone: 9196446714

CMS Overall:4/5

Overview & Bed Count

Certified Beds
80
Avg Residents/Day
72.2
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Orange
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall4/5
Health4/5
Staffing4/5
Quality4/5

Nurse Staffing Check

MetricThis FacilityNorth Carolina AvgDifference
RN Hours per Resident per Day0.570.62-0.06
Total Nurse Hours per Resident per Day3.693.87-0.18
CMS Staffing Rating4/52.7/5-
Nursing Staff Turnover44.0%48.7%-

Health Citation History

13 health citations on record

DateCategoryDescriptionSeverity
2026-04-16Resident Rights DeficienciesProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.B – Minimal Harm Potential
2025-02-28Resident Rights DeficienciesImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.D – Moderate Harm Potential
2025-02-28Resident Rights DeficienciesProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.D – Moderate Harm Potential
2025-02-28Resident Rights DeficienciesNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.D – Moderate Harm Potential
2025-02-28Resident Rights DeficienciesPermit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.D – Moderate Harm Potential
2025-02-28Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential
2025-02-28Quality of Life and Care DeficienciesProvide or obtain dental services for each resident.D – Moderate Harm Potential
2025-02-28Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2024-03-16Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D – Moderate Harm Potential
2023-10-27Resident Assessment and Care Planning DeficienciesEnsure each resident receives an accurate assessment.E – Moderate Harm Potential
2023-10-27Nutrition and Dietary DeficienciesEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.E – Moderate Harm Potential
2023-10-27Resident Rights DeficienciesAllow residents to self-administer drugs if determined clinically appropriate.D – Moderate Harm Potential
2023-10-27Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential

Fire Safety Citation History

14 fire safety citations on record

DateCategoryDescriptionSeverity
2026-04-16Egress DeficienciesKeep aisles, corridors, and exits free of obstruction in case of emergency.D – Moderate Harm Potential
2026-04-16Smoke DeficienciesProperly install and monitor supervisory attachments on automatic sprinkler systems.D – Moderate Harm Potential
2026-04-16Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.D – Moderate Harm Potential
2025-02-28Construction DeficienciesUse approved construction type or materials.D – Moderate Harm Potential
2025-02-28Gas, Vacuum, and Electrical Systems DeficienciesHave proper medical gas storage and administration areas.D – Moderate Harm Potential
2023-10-27Construction DeficienciesUse approved construction type or materials.F – Moderate Harm Potential
2023-10-27Smoke DeficienciesInstall a fire alarm system that can be heard throughout the facility.E – Moderate Harm Potential
2023-10-27Smoke DeficienciesInstall smoke barrier doors that can resist smoke for at least 20 minutes.E – Moderate Harm Potential
2023-10-27Miscellaneous DeficienciesMeet Health Care Facilities Code mechanical requirements.E – Moderate Harm Potential
2023-10-27Gas, Vacuum, and Electrical Systems DeficienciesMeet requirements for the installation and maintenance of electrical systems.E – Moderate Harm Potential
2023-10-27Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.D – Moderate Harm Potential
2023-10-27Smoke DeficienciesInstall corridor and hallway doors that block smoke.D – Moderate Harm Potential
2023-10-27Services DeficienciesHave properly installed electrical wiring and gas equipment.D – Moderate Harm Potential
2023-10-27Gas, Vacuum, and Electrical Systems DeficienciesHave proper medical gas storage and administration areas.D – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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