Peak Resources - Alamance, Inc

In the surveyor’s words

From the most serious findings on record at Peak Resources - Alamance, Inc, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 1, 2026

  Based on record reviews, observations, and resident, Nurse Practitioner (NP), and staff interviews, the facility failed to provide a safe transfer for 1 of 3 residents reviewed for preventing avoidable accidents (Resident #1). On 06/19/2026 (exact time unknown), Resident #1 was in her room with Nurse Aide (NA) #1 and NA #2. NA #2 stood at the side of her bed preparing to assist with transferring. Resident #1 reported that she tried to tell NA #2 that she did not have strength in her back, that she would need the arm rail to assist with getting up, and that she could not lift her arms above her shoulders. NA #2 assured her, then wrapped her arms around Resident #1's torso and lifted her off the bed. […]

• No harm, potential for more than minimal, patternF761Mar 5, 2026

  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. […]

• No harm, potential for more than minimal, patternF812Aug 11, 2023

  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. […]

• No harm, potential for more than minimal, isolatedF627Mar 5, 2026

  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… […]

• No harm, potential for more than minimal, isolatedF641Mar 5, 2026

  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. […]