Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Peak Resources - Alamance, Inc during CMS and state inspections, most recent first.
A resident with CHF, chronic respiratory failure, polyneuropathy, and limited mobility required 2-person assist for transfers, but an aide lifted her from bed in a way that did not follow her documented transfer status. During the transfer, her arm struck the wheelchair, she felt pain and heard a popping sound, and she later required an X-ray and ED evaluation that confirmed a proximal humerus fracture.
Surveyors found multiple medication storage and labeling deficiencies in two medication storerooms, including expired Allegra D and nicotine patches left on a shelf, and a glucagon pen for a resident stored in a refrigerator contrary to manufacturer instructions requiring room temperature storage. In another storeroom, an opened multi-dose vial of Tuberculin PPD was kept in a refrigerator without any notation of the date it was opened, despite manufacturer directions that it be discarded 30 days after opening. The unit manager and DON acknowledged that nursing staff and supervisors share responsibility for ensuring medications are in date, properly stored, and labeled when opened.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident with an underactive bladder had an indwelling urinary catheter discontinued and was receiving intermittent catheterizations, yet subsequent quarterly MDS assessments continued to code an indwelling catheter. Another resident receiving an antipsychotic, antidepressant, and diuretic, with no opioid orders or administration, was coded on the MDS as receiving an opioid and had no documented indications for use recorded for any of the medications. The MDS nurse acknowledged these coding errors and omissions during interviews.
A resident with a right foot fracture, cerebral palsy, and muscle weakness, who required assistance with several ADLs and was receiving PT/OT, had a documented goal to return home with home health services. Although orders and therapy discharge summaries specified discharge home with home health PT, OT, and case management, the care plan and progress notes lacked discharge planning details, and the discharge plan stated that home health would be arranged prior to discharge. The resident was discharged home and later reported that she had been told home health would be set up before leaving but did not hear from the agency until several days afterward, relying on friends for help. Interview and documentation from the home health agency and a fax confirmation showed that the facility did not send the referral until the day after discharge, resulting in a delay in initiation of home health services.
A resident with cognitive and developmental disabilities fell from a mechanical lift due to improper use by two nurse aides. The resident was lifted into the air, but one aide let go of the hand holds, causing the resident to slide out and fall. The resident was assessed for injuries and diagnosed with a scalp hematoma. The facility conducted a root cause analysis and provided reeducation on proper lift techniques.
The facility's QAPI committee failed to maintain procedures and monitor interventions, resulting in a repeat deficiency in supervision to prevent accidents. During a complaint investigation, the facility failed to prevent a fall from a mechanical lift and provide safe incontinent care for residents.
Unsafe Transfer Resulted in Shoulder Fracture
Penalty
Summary
The facility failed to provide a safe transfer for a resident who required assistance with bed mobility and transfers. The resident had acute chronic diastolic congestive heart failure, chronic respiratory failure with hypoxia, a history of pulmonary embolism, obesity, unspecified pain, and polyneuropathy. Her therapy plan showed she required partial to moderate assistance for lying-to-sitting and sit-to-stand transfers, and her care plan/profile identified one-person assistance for bed mobility and two-person assistance for stand-pivot transfers. On the day of the incident, two nurse aides were assisting the resident with getting up for therapy. The resident stated that she told the aide assisting her that she did not have strength in her back, needed the arm rail to help get up, and could not lift her arms above her shoulders. Despite this, the aide wrapped her arms around the resident’s torso and lifted her off the bed. The resident reported that her feet were not touching the floor and that the transfer was hurting her. She also stated that her right arm struck the wheelchair arm and was forced upward during the transfer, causing pain and a popping sound. After the transfer, the resident became dizzy and lightheaded and could not communicate what had happened. Nursing assessment documented right shoulder and elbow pain, limited range of motion, and an X-ray that showed malalignment of the right humerus and shoulder joint, later confirmed in the emergency department as a proximal humerus fracture. Interviews with the resident, the nurse aide who observed the event, and facility leadership described that the resident required two-person assistance, but the transfer was performed in a manner inconsistent with her documented transfer status.
Expired, Improperly Stored, and Undated Medications in Medication Storerooms
Penalty
Summary
Surveyors identified deficiencies in the facility’s handling and storage of medications in two medication storerooms. In the Station 1 Medication Storeroom, an observation revealed an unopened box of Allegra D with a manufacturer’s expiration date of November 2025 that was expired, and an opened box of 14 mg nicotine transdermal patches with a manufacturer’s expiration date of January 2026 that was also expired. Additionally, an unopened 1 mg glucagon pen dispensed for Resident #43 was found stored in the medication storeroom refrigerator at 40°F, despite the manufacturer’s label directing storage at controlled room temperature between 68°F and 77°F. The Station 1 Unit Manager acknowledged responsibility for checking the storeroom to ensure medications were not expired and were stored properly. The DON later stated that everyone, including supervisors, was responsible for checking the medication storeroom and confirmed that glucagon should not be stored in the refrigerator. In the Station 3 Medication Storeroom, surveyors observed an opened multi-dose vial of Tuberculin PPD injectable solution in the medication storeroom refrigerator. The vial and its manufacturer’s box, dispensed from the pharmacy on January 28, 2026, were not labeled with the date the vial was opened, preventing determination of the shortened expiration date. Manufacturer instructions for the multi-dose PPD vial indicated it should be discarded 30 days after opening. Nurse #1 stated the vial would need to be discarded. During an interview, the DON reiterated that everyone, including supervisors, was responsible for checking the medication storeroom to ensure medications were properly stored and within date, and stated that she expected the nurse who opened a medication to date the label with the opening date.
Inaccurate MDS Coding for Catheter Use and Medication Regimen
Penalty
Summary
The deficiency involves inaccurate coding of MDS assessments for two residents, resulting in failure to ensure accurate resident assessments. For one resident with a diagnosis including flaccid neuropathic (underactive) bladder, physician orders initially directed use of an indwelling urinary catheter with catheter care every shift, and later discontinued the indwelling catheter in favor of intermittent catheterization as needed. Nursing documentation on the MAR showed catheter care every shift from early July through mid-August, consistent with the indwelling catheter order until it was discontinued. However, the quarterly MDS assessments completed after the resident had transitioned to intermittent catheterization continued to code the resident as having an indwelling urinary catheter. The MDS coordinator who completed these assessments acknowledged during interview that the resident no longer had an indwelling catheter at the time of the assessments and that the MDS should have been coded to reflect intermittent catheter use instead. For another resident admitted with mood disorder, major depressive disorder, pain, and later localized edema, physician orders and the MAR showed daily administration of Risperdal for mood disorder, Duloxetine for major depressive disorder, and Furosemide/Lasix for localized edema, with no orders or administration of opioid medications. A quarterly MDS assessment for this resident, completed by the same MDS nurse, coded the resident as receiving medications from the antipsychotic, antidepressant, diuretic, and opioid drug classes, and did not document indications for use for any of these medications. During interview, the MDS nurse stated that omitting the indications for use was an oversight, confirmed that the resident had diagnoses supporting the use of antipsychotic, antidepressant, and diuretic medications, and acknowledged that the resident did not receive any opioid medications and that coding opioid use was a mistake.
Failure to Arrange Timely Home Health Referral Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective discharge planning process to ensure timely referral for home health services prior to a resident’s discharge home. The resident had diagnoses including a displaced fracture of the right second metatarsal, cerebral palsy, and muscle weakness, and required assistance or supervision with several ADLs. The 5‑day MDS documented that the resident was cognitively intact, receiving PT and OT, and had an overall discharge goal of returning to the community with active discharge planning noted. However, the resident’s care plan dated 01/10/2025 contained no information related to discharge planning, and progress notes from 01/07/2025 through 01/31/2025 contained no documentation of discharge planning activities. Therapy documentation showed that the resident exhausted therapy benefits on 01/25/2025 and would require home health OT and PT upon discharge. An order dated 01/28/2025 directed discharge home with home health PT, OT, and case management services. The OT and PT discharge summaries indicated that the interdisciplinary team was to coordinate a discharge that included home health services. A nurse practitioner documented a face‑to‑face encounter on 01/30/2025, certified the resident as homebound, ordered home health PT and OT, and indicated that required home health documentation was reviewed and communication with the home health agency occurred. Despite these orders and certifications, there was no evidence in the record that a referral to home health was actually sent before the resident left the facility. The resident was discharged home on 01/31/2025, with the discharge/transfer plan of care stating that she was to be set up with home health PT, OT, and case management prior to discharge and that she left by car with a friend. The resident later reported that the social worker had told her home health services would be arranged before she went home, but she did not hear from home health until several days after discharge and relied on friends for help in the interim. Home health records and interview confirmed that the referral paperwork, which included a home health order dated 01/28/2025, was first received by the home health agency on 02/01/2025, after the resident had already been discharged. A fax confirmation from the facility also showed the referral was sent on 02/01/2025, and there was no evidence of any earlier referral, demonstrating that the facility did not complete the home health referral prior to discharge as planned.
Failure to Prevent Fall from Mechanical Lift
Penalty
Summary
The facility failed to prevent a fall from a mechanical lift for a resident with multiple diagnoses, including a cognitive and developmental disability and spinal stenosis. The incident occurred when two nurse aides were transferring the resident using a mechanical lift. The resident was placed on a lift pad and lifted into the air, but one of the nurse aides let go of the hand holds on the lift pad, causing the resident to slide out of the top of the lift pad and fall to the floor. The resident was assessed for injuries and sent to the emergency room, where a scalp hematoma was diagnosed, but no major trauma or pain was noted. The nurse aides involved in the incident confirmed that they had used the same-colored straps on the hooks of the mechanical lift and crossed the straps between the resident's legs to keep her secure. However, one of the nurse aides removed her hands from the hand holds on the lift pad to move the wheelchair into position, which led to the resident sliding out of the lift pad. The Director of Nursing (DON) conducted a root cause analysis and determined that the lift pad was positioned incorrectly during the transfer, and a nurse aide let go of the hand holds while the resident was in the air. The DON and the nursing staff recreated the incident to identify the errors and provided reeducation on the proper use of the mechanical lift. The staff were trained on how to access the resident profile for choosing the correct lift pad, ensuring wheelchairs are in position before starting the transfer, and always keeping hold of the hand holds while the resident is in the air. The facility also conducted competency checks and audits to ensure proper mechanical lift techniques were being followed by the nursing staff.
Repeat Deficiency in Supervision to Prevent Accidents
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions following a complaint investigation completed on 9/19/2023. This resulted in a repeat deficiency in the area of supervision to prevent accidents. Specifically, during a complaint investigation on 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. Additionally, during the complaint investigation on 9/19/2023, the facility failed to provide safe incontinent care for one of three residents reviewed for accidents. The Administrator confirmed that the QAPI committee, which includes various department heads, was not effectively sustaining the QAPI process, as evidenced by the repeated deficiencies and non-compliance identified by the corporate office after the fall incident involving a resident and a mechanical lift.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Graham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alamance Health Care Center | 1.6 mi | ★★★★★ | 10 | 0 |
| White Oak Manor - Burlington | 1.9 mi | ★★★★★ | 3 | 0 |
| Edgewood Place At The Village At Brookwood | 3.4 mi | ★★★★★ | 0 | 0 |
| Liberty Commons Nursing & Rehabilitation Center Of | 5.5 mi | ★★★★★ | 2 | 0 |
| Twin Lakes Community | 6.7 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.