Peak Resources-Wilmington, Inc

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 2, 2026

  Based on observations, record review, and interviews with staff, Responsible Party (RP), Nurse Practitioner (NP), and Medical Director, the facility failed to provide the necessary supervision to prevent Resident #1, a resident with severe cognitive impairment and a known history of an unsupervised exit, from leaving the facility at night without staff's knowledge when the outside temperature was 30 degrees Fahrenheit (F). On 2/9/2026 at approximately 11:55 PM, two individuals unknown to the facility who had been walking through the facility's parking lot, returned Resident #1 in her wheelchair to the facility and alerted Nurse #3 that they had found the resident outside by herself, sitting in a ditch. Staff were unaware the resident was missing and outside unsupervised. […]

• Actual harm, isolatedF689May 22, 2026

  Based on record review, and interviews with staff, resident, and the Physician Assistant, the facility failed to transfer Resident #17 using a mechanical lift, placing the resident at risk for an avoidable injury. On 11/19/25, Nurse Aide #1 attempted to transfer Resident #17 from her bed using a slide board (a board used to transfer a resident from one sitting position to another such as chair, bed, etc.). At the time of the transfer, staff had not yet been educated or trained by the Therapy Department for the use of a slide board for transferring Resident #17 and Resident #17 fell to the floor. […]

• Actual harm, isolatedF600Jan 12, 2024

  Based on observations, record review, and Psychiatric Nurse Practitioner, Physician Assistant, and staff interviews, the facility failed to protect a vulnerable female resident's right to be free from sexual abuse when Resident #62 was observed by Nurse Aide (NA) #1 to have his hand under a severely cognitively impaired resident's (Resident #57) dress above the resident's thigh. A reasonable person would not expect to experience intentional inappropriate touching in their home and would have experienced intimidation and fear. This was for 1 of 5 residents reviewed for abuse (Resident #57). Findings included: Resident #62 was admitted to the facility on [DATE]. Diagnoses included stroke with weakness, non-traumatic brain dysfunction, depression, and vascular dementia. […]

• Actual harm, isolatedF689Apr 15, 2021

  Based on record review, resident interview and staff and Physician interviews, the facility failed to follow the resident ' s care plan to utilize two staff members with bed mobility for 1 of 2 residents observed for falls. Resident #43 sustained a fall which resulted in a left fractured femur that required surgery. Findings included: Resident #43 was admitted to the facility on [DATE], discharged on [DATE] to the hospital and readmitted to the facility on [DATE]. Diagnoses included, in part, fracture to left femur (02/09/21) and stroke with left side weakness. A care plan dated 04/19/19 and last reviewed on 02/26/21 revealed a plan of care for Activity of Daily Living (ADL) self-care deficit related to stroke with left sided [CONDITION(S)] and [CONDITION(S)]. […]

• No harm, potential for more than minimal, widespreadF814May 22, 2026

  Based on observations and staff interviews, the facility failed to ensure the dumpster area and exterior exit leading to the dumpster area remained free of garbage and refuse for 2 of 2 dumpsters. This failure had the potential to attract pests and rodents. Findings included: An initial observation of the kitchen exterior exit leading to the dumpster area with the two dumpsters was made on 5/18/26 at 11:37 AM with the Dietary Manager (DM). Observed next to the dumpster area wall were scattered leaves, broken tree limbs, a discarded large white wooden door, a large pile of broken pieces of white door trim, seven intact wooden pallets, and a large quantity of scattered cigarette butts. […]