Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Peak Resources - Pinelake during CMS and state inspections, most recent first.
A cognitively impaired male resident with dementia and behavioral issues physically grabbed the arm of another cognitively intact male resident as he exited the bathroom, resulting in minor redness to the latter's shoulder. Staff witnessed and intervened in the incident, which was later substantiated as resident-to-resident abuse due to the facility's failure to prevent the altercation.
A resident with Dementia, Diabetes, and Congestive Heart Failure experienced significant declines in weight, skin condition, and mobility, including a diagnosis of Osteomyelitis. Despite these changes, the facility failed to complete a significant change MDS, conducting only a quarterly MDS instead. Interviews with staff confirmed the oversight.
The facility failed to accurately display nurse staffing information for several days, with discrepancies between the actual staff schedule and the posted information. Errors included incorrect counts of NAs, LPNs, and RNs due to counting mistakes and date mix-ups, as confirmed by the Human Resource Coordinator.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A deficiency occurred when a severely cognitively impaired male resident with Alzheimer's dementia and behavioral disturbances physically grabbed the arm of a cognitively intact male resident as the latter was exiting the bathroom. The incident took place when the impaired resident, using a wheelchair, attempted to enter the bathroom and ran into the other resident, subsequently grabbing his arm. The cognitively intact resident responded by hitting the impaired resident's hands in an attempt to free himself. Staff members, including a nurse aide and a nurse, witnessed the event and intervened to separate the residents. The resident who initiated the physical contact had a history of dementia-related behavioral symptoms and was under a care plan that included interventions for managing such behaviors, including medication management and environmental modifications. At the time of the incident, the resident's antipsychotic medication had recently been reduced due to drowsiness, and he was also being evaluated for a urinary tract infection, which can contribute to confusion and behavioral changes. The resident did not recall the incident afterward, consistent with his cognitive impairment. The incident was witnessed by staff, and both residents were assessed for injuries, with one resident showing some redness on his shoulder. Law enforcement was notified, and both residents were interviewed, but neither wished to press charges. The event was substantiated as resident-to-resident abuse based on witness statements and the facility's investigation. The deficiency was identified as a failure to protect a resident's right to be free from abuse by another resident.
Failure to Complete Significant Change MDS for Resident
Penalty
Summary
The facility failed to identify the need for a significant change Minimum Data Set (MDS) for a resident who experienced declines in weight, skin condition, and activities of daily living. This deficiency was identified for a resident admitted with Dementia, Diabetes, and Congestive Heart Failure, who was later diagnosed with Osteomyelitis. The resident's previous quarterly MDS did not reflect any weight loss, skin conditions, or the use of a wheelchair, and indicated the resident required supervision for various mobility and transfer activities. Subsequent assessments revealed significant changes, including unprescribed weight loss, a diabetic foot ulcer, and increased dependency on staff assistance for mobility and transfers. Despite these changes, a significant change MDS was not completed, and instead, a quarterly MDS was conducted. Interviews with the MDS nurse and the Administrator confirmed that a significant change MDS should have been completed, acknowledging the oversight in the resident's assessment process.
Inaccurate Nurse Staffing Information Displayed
Penalty
Summary
The facility failed to display accurate Posted Nurse Staffing Information for 4 out of 30 days reviewed. On multiple occasions, discrepancies were found between the Staff Schedule/Assignment Sheet and the Posted Nurse Staffing information. For instance, on 07/19/24, the Posted Nurse Staffing indicated 11 Nursing Assistants (NAs) worked, while the actual schedule showed only 10 NAs. Similar inconsistencies were noted on 07/21/24, where the number of NAs, Licensed Practical Nurses (LPNs), and Registered Nurses (RNs) listed on the Posted Nurse Staffing did not match the actual staff working according to the schedule. These discrepancies were repeated on 07/22/24 and 07/23/24, with variations in the reported and actual numbers of NAs, LPNs, and RNs working different shifts. Interviews with the Human Resource Coordinator revealed that errors in the staffing sheets were due to counting an unlicensed staff member twice and mixing up dates, leading to incorrect postings. The Coordinator confirmed that the staffing sheets for the specified dates did not match the staff posting sheets. The Administrator also acknowledged the expectation that the daily nurse staff sheets and assignment sheets should accurately reflect the correct number of staff working, indicating a failure in maintaining accurate staffing records.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Carthage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Greens At Pinehurst Rehabilitation & Living Ce | 9.2 mi | ★★★★★ | 11 | 0 |
| Saint Joseph Of The Pines Health Center | 10.5 mi | ★★★★★ | 9 | 0 |
| Penick Village | 11.1 mi | ★★★★★ | 3 | 0 |
| Pinehurst Healthcare & Rehabilitation Center | 11.5 mi | ★★★★★ | 7 | 0 |
| Inn At Quail Haven Village | 11.5 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.