Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 - Brookshire, Inc during CMS and state inspections, most recent first.
The facility failed to send the Ombudsman copies of required Notices of Transfer/Discharge for three residents who were discharged to an assisted living facility, discharged home, or transferred to a hospital for acute care. Instead of forwarding the actual notices on the date they were issued, staff emailed periodic Admit/Discharge Reports that only listed resident names, discharge dates, and destinations. The Social Worker, DON, and Administrator all reported they believed these summary reports met the requirement, despite prior education from the Ombudsman that copies of all transfer/discharge notices for all discharges and emergency transfers must be provided.
A facility failed to notify a physician when a dental service consultation for a tooth extraction could not be scheduled for a resident with a history of dental issues. The resident required hospital-based treatment due to health concerns, but the Unit Manager delayed sending a referral and did not follow up. The resident experienced tooth pain, and the physician was not informed of the scheduling issue, preventing timely alternative arrangements.
A facility failed to provide timely written notification to a resident and their responsible party regarding the reason for the resident's transfer to the hospital. The resident, who was cognitively intact and had a diagnosis of Type 2 diabetes mellitus with a foot ulcer, was aware of the need to be transferred to the emergency room for evaluation. However, there was no evidence in the records that a discharge or transfer notice was sent to the resident or their responsible party. The Business Office Manager acknowledged missing the notification process, which was discovered during an audit.
A facility failed to provide a resident with written notification of the bed hold policy upon transfer to the hospital. The resident, who had Type 2 diabetes with a foot ulcer, was transferred to the emergency room but did not receive the bed hold policy. Staff interviews revealed lapses in procedure, with the Business Office Manager failing to follow up due to being off-duty. Consequently, the resident was discharged to another facility when no beds were available upon hospital discharge.
A facility failed to allow a resident to return after hospitalization due to a lack of available beds, violating the bed-hold policy. The resident, who was cognitively intact and had diabetes with a foot ulcer, was discharged to another facility. The Admissions Coordinator did not communicate the bed-hold policy or offer a bed when one became available. The Administrator was unaware of the requirement to allow residents to return to the first available bed.
The facility failed to develop individualized care plans for three residents, neglecting areas such as pain management, anticoagulant and diuretic use, and behavioral needs. A resident with pain did not have a care plan despite being on pain medication. Another resident on anticoagulants and diuretics lacked a care plan focus for these medications. Additionally, a cognitively impaired resident using markers inappropriately did not have a care plan addressing the need for non-toxic markers and staff redirection.
A resident with multiple health conditions required a tooth extraction, but the facility failed to obtain the necessary dental services. Despite being referred to an oral surgeon, the procedure could not be performed in an outpatient setting due to the resident's need for IV sedation. The facility delayed sending a referral to a dental school and did not follow up, resulting in the resident not receiving the required dental care.
The facility failed to implement infection control policies when a nurse aide and a housekeeper did not wear the required PPE before entering rooms with residents on special contact-droplet precautions. The nurse aide entered a resident's room with only a surgical mask, and the housekeeper was observed mopping with insufficient PPE, despite signage indicating the need for full protective gear. Both staff members were unaware of the requirements, and the Director of Nursing noted that staff were not reading the signs.
Failure to Send Required Transfer/Discharge Notices to Ombudsman
Penalty
Summary
The deficiency involves the facility’s failure to provide the Ombudsman with copies of the required Notices of Transfer/Discharge for three residents who were discharged or transferred. For one resident, admitted on an unspecified date, the Discharge/Transfer Plan of Care form showed a discharge to an assisted living facility on 1/14/26 after health needs had been met. Progress notes and the facility’s Admit/Discharge Report for 1/1/26–1/31/26 confirmed this discharge to another health care institution. The Social Worker reported that she emailed the Ombudsman the Admit/Discharge Report on 2/3/26, which listed the resident’s discharge, but she did not send the actual Notice of Transfer/Discharge and stated she was unaware this was required. The Ombudsman confirmed she did not receive the notice and stated she had previously educated the Social Worker and Administrator that copies of all Notices of Transfer/Discharge for all discharges and emergency transfers must be sent on the date the notice is issued. A second resident, also admitted on an unspecified date, was discharged home on 12/17/25, as documented in a progress note and the Admit/Discharge Report for 12/1/25–12/31/25. The Social Worker stated that on 1/8/26 she emailed the Ombudsman the Admit/Discharge Report for that period, which showed the resident’s discharge home, but again did not send a copy of the Notice of Transfer/Discharge and reported she did not know this was required. The Ombudsman confirmed she did not receive the notice for this discharge and reiterated that she had educated the Social Worker and Administrator that the Ombudsman must receive a copy of all Notices of Transfer/Discharge for all discharges and emergency transfers on the date the notice is issued. The Administrator acknowledged receiving education from the Ombudsman but stated he believed that sending the Admit/Discharge Report fulfilled the requirement. The third resident, admitted on an unspecified date, was transferred to the hospital on 1/22/26 for evaluation and treatment of an acute abdominal condition that could not be treated in the facility, following a request from the resident’s representative and an order from the provider. The Admit/Discharge Report for 1/1/26–1/31/26 showed this transfer as a discharge with expected return for inpatient care. The Social Worker stated she emailed the Ombudsman the Admit/Discharge Report on 2/3/26, which included the resident’s name and hospital admission location, but she did not send the Notice of Transfer/Discharge and believed only basic discharge information (name, date, location) was required. The Ombudsman confirmed she did not receive the notice for this hospital transfer and stated she had previously instructed the facility to send copies of all Notices of Transfer/Discharge for all discharges and emergency transfers on the date issued. The DON and Administrator both reported they were unaware that the actual transfer documents, rather than summary report data, were required to be sent to the Ombudsman.
Failure to Notify Physician of Dental Service Scheduling Issue
Penalty
Summary
The facility failed to notify the physician when a dental service consultation for a tooth extraction could not be scheduled for a resident. The resident, who was cognitively intact, had a history of dental issues including exfoliation of teeth due to systemic causes and a periapical abscess. A consultation on 12/5/24 revealed that the resident was not a candidate for treatment in an office setting due to her health history and required the procedure to be done in a hospital setting. The Unit Manager received this consultation report and faxed it to the contracted mobile dentist but did not follow up promptly. The Unit Manager delayed sending a referral to a dental school until 1/22/25 and did not follow up to confirm if the resident could be seen for the procedure. The resident expressed having tooth pain, and the contracted mobile dentist noted sensitivity and pain during an exam. The physician was not informed of the difficulty in scheduling the procedure, which could have allowed her to seek alternatives. The physician noted the importance of addressing the resident's dental needs outside of an emergency setting, highlighting the facility's failure to communicate effectively and ensure timely care for the resident's dental condition.
Failure to Notify Resident and Responsible Party of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident and their responsible party regarding the reason for the resident's transfer to the hospital. The resident, who was cognitively intact and had a diagnosis of Type 2 diabetes mellitus with a foot ulcer, was aware of the need to be transferred to the emergency room for evaluation. However, there was no evidence in the records that a discharge or transfer notice was sent to the resident or their responsible party. The resident was discharged to the hospital for an acute condition and did not return to the facility. Interviews with facility staff revealed that the Business Office Manager (BOM) was responsible for issuing the discharge/transfer notice but failed to do so in this instance. The BOM acknowledged missing the notification process, which was discovered during an audit conducted by the Regional Business Office Manager. The facility's administrator confirmed that the notice of transfer should have been provided to the resident and/or their responsible party.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy when a resident was transferred to the hospital. This deficiency was identified for a resident who was admitted with a diagnosis of Type 2 diabetes mellitus with a foot ulcer. The resident was cognitively intact and was aware of the need to be transferred to the emergency room for evaluation. However, there was no evidence that the bed hold policy was sent with the resident when he was unexpectedly discharged to the hospital. Consequently, when the resident was ready to discharge from the hospital, he was informed that there were no beds available at the facility, and he was discharged to another rehabilitation facility. Interviews with facility staff revealed that the Director of Nursing stated that nurses usually print copies of the bed hold policy to send with the hospital transfer form, but this was not documented. Nurse #3 mentioned that the bed hold policy was usually sent but sometimes they ran out of copies. The Business Office Manager admitted that the bed hold policy was not sent to the resident or his responsible party, as she was off the day the resident was sent to the hospital and failed to follow up. The Administrator was unaware of the requirement to allow a discharged resident to return to the first available bed when none were available at the time of their discharge from the hospital.
Failure to Allow Resident Return Post-Hospitalization
Penalty
Summary
The facility failed to allow a resident to return after hospitalization, violating the bed-hold policy. Resident #70, who was cognitively intact and had diagnoses including type 2 diabetes mellitus with a foot ulcer and cellulitis, was transferred to the hospital for an acute condition. Upon discharge from the hospital, the resident was informed that there were no available beds at the facility and was subsequently discharged to another rehabilitation facility. The facility's failure to provide the bed-hold policy to the resident or his responsible party contributed to this issue. Interviews with the Admissions Coordinator revealed that she did not communicate the bed-hold policy to the resident or his responsible party and did not offer a bed when one became available. The facility census on the day of the resident's discharge showed only one semiprivate female bed was available, and the Admissions Coordinator admitted to not offering it to the resident. The Administrator was unaware of the requirement to allow residents to return to the first available bed when no beds were available at the time of hospital discharge. Attempts to contact the hospital case manager for further clarification were unsuccessful.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized person-centered care plans for three residents in key areas such as pain management, anticoagulant and diuretic use, and behaviors. Resident #32, who was admitted with a diagnosis that included pain, did not have a care plan for pain management despite being prescribed Oxycodone and Gabapentin. The MDS Coordinator acknowledged the oversight in not developing a comprehensive care plan for Resident #32's pain management. Similarly, Resident #21, who was admitted with atrial fibrillation and essential hypertension, was prescribed Eliquis and furosemide, but their care plan lacked a focus on anticoagulant and diuretic use. The MDS Nurse confirmed that these elements should have been included in the care plan. Resident #63, who was cognitively impaired and had a history of using markers inappropriately, did not have a care plan that addressed the need for only non-toxic markers and staff redirection. Despite observations and staff awareness of the behavior, the care plan was not updated to reflect these needs. Interviews with the Activities Director, Unit Manager, and Medical Director revealed that while non-toxic markers were provided, there was concern for Resident #63's safety, and the care plan should have been revised to address the behavior. The DON confirmed that the change in behavior was discussed in meetings, but the care plan was not updated accordingly.
Failure to Obtain Recommended Dental Services for Resident
Penalty
Summary
The facility failed to obtain recommended dental services for a resident, identified as Resident #32, who was admitted with multiple health conditions including exfoliation of teeth due to systemic causes, hypertensive heart disease, chronic kidney disease, and a periapical abscess. Despite being cognitively intact and not exhibiting significant pain or weight changes, Resident #32 required a tooth extraction due to sensitivity and possible nerve damage. The contracted mobile dentist initially examined her and referred her to an oral surgeon for the procedure, which could not be performed in an outpatient setting due to her need for IV sedation and her medical conditions. The oral surgeon recommended that the procedure be done in a hospital setting, but the facility did not follow up promptly. The Unit Manager delayed sending a referral to a dental school until over a month after the oral surgeon's consultation and did not follow up to confirm if the procedure could be completed. The Social Worker, responsible for completing referrals, was unaware of the oral surgeon's recommendations and had not been informed to assist in finding a hospital for the procedure. Consequently, Resident #32 had not been seen by a dentist for an oral exam since the oral surgeon's consultation. Interviews with the Director of Nursing and the resident's physician revealed that the facility had not effectively coordinated the necessary dental care. The physician noted the difficulty in finding a dentist to perform the procedure under general anesthesia due to the resident's health conditions. The facility's lack of timely follow-up and coordination resulted in the resident not receiving the required dental extraction, despite the resident being clinically stable and not exhibiting significant pain.
Failure to Implement Infection Control Policies
Penalty
Summary
The facility failed to implement its infection control policies and procedures when two staff members, Nurse Aide #1 and Housekeeper #1, did not don the required Personal Protective Equipment (PPE) before entering rooms with residents on special contact-droplet precautions. Nurse Aide #1 entered a resident's room wearing only a surgical mask to deliver a lunch meal tray, despite the signage indicating the need for full PPE due to the resident being on isolation precautions for Respiratory Syncytial Virus (RSV) and Influenza. Nurse Aide #1 expressed confusion, believing that full PPE was not necessary if not providing direct patient care. Similarly, Housekeeper #1 was observed mopping the floor in another resident's room while wearing only a surgical mask and gloves, contrary to the special droplet contact precautions signage that required a gown, N95 respirator, and face shield. Housekeeper #1 was unaware of the PPE requirements, and the Director of Nursing acknowledged that staff were not reading the signs, attributing this to the facility not having had an isolation case in a while. The Administrator also indicated that staff should read the signs to understand the necessary precautions before entering a room.
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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 Hillsborough
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth-carolina Point | 7.4 mi | ★★★★★ | 3 | 0 |
| Croasdaile Village | 7.9 mi | ★★★★★ | 6 | 0 |
| Carol Woods | 7.9 mi | ★★★★★ | 0 | 0 |
| University Health And Rehabilitation Center | 8.4 mi | ★★★★★ | 21 | 0 |
| Pruitthealth-durham | 8.7 mi | ★★★★★ | 32 | 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.