Peak Resources-Wilmington, Inc

Inspectors wroteBased 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. Results from x-rays noted a fractured left humerus (long bone in the upper arm), mildly displaced fracture of left tibia (shin bone) and right medial malleolus (inner side of ankle), and a partial dislocated shoulder. Resident #17 was sent to the Emergency Department for further evaluation. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on record review, staff and Nurse Practitioner interviews, the facility failed to obtain consent and inform the resident or resident representative in advance of the risks and benefits of psychotropic medications for 9 of 9 residents reviewed for unnecessary medications (Resident #8, #31, #46, #84, #27, #12, #3, #6, and #9).

Inspectors wroteBased on record review, and staff, resident and the Physician Assistant interviews, the facility failed to provide a resident with dignity and respect when she was not provided incontinence care when requested and was left in a soiled brief and felt gross as a result of having to wait. This was for 1 of 2 residents observed for dignity (Resident #3).

Inspectors wroteBased on record review, and staff and Physician Assistant (PA) interviews, the facility failed to notify the provider and responsible party (RP) of transfer from dialysis to the emergency department (ED) due to a shunt bleeding event at dialysis for 1 of 2 sampled resident reviewed for dialysis (Resident #2).

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to provide incontinence care to 1 of 2 dependent residents reviewed for activity of daily living (ADL) care (Resident #9).

Inspectors wroteBased on record review and staff, Physician Assistant (PA), and Pharmacy Services Director interviews, the facility failed to provide the discharge summary needed for the pharmacist to conduct a comprehensive medication review. As a result, the pharmacist did not identify a medication error, leading to the administration of 27 doses of the anticoagulant Eliquis (a prescription blood thinner used to prevent and treat blood clots and reduce stroke risk) for 1 of 5 residents reviewed for unnecessary medications (Resident #8).

Inspectors wroteBased on record review and staff, Physician Assistant (PA), Physician and Pharmacy Manager interviews, the facility failed to discontinue an anticoagulant medication following readmission to the facility resulting in 27 doses of the anticoagulant Eliquis (a prescription blood thinner used to prevent and treat blood clots and reduce stroke risk) administered in error to a resident that was a high fall risk. This occurred for 1 of 5 residents reviewed for unnecessary medications (Resident #8).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) when providing direct care activities to Resident #9 who had a Stage IV pressure ulcer on his heel. This occurred with 1 of 3 staff members observed for infection control practices (Treatment Nurse).

Inspectors wroteBased 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. [...]

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to treat residents in a dignified manner as evidenced by staff interactions with residents that included cursing, slamming doors and arguing with residents for 3 of 5 residents reviewed for dignity (Resident #26, Resident #54, and Resident #85).

Inspectors wroteBased on record review and interviews with resident, staff, and Physician Assistant (PA), the facility failed to protect the resident's right to be free from physical abuse when the resident reported pain during care and the Nurse Aide (NA) willfully disregarded the resident's complaint and continued to provide care to the resident despite the NA's knowledge that she was hurting the resident. The deficient practice occurred for 1 of 3 residents reviewed for abuse (Resident #25).

Inspectors wroteBased on record review, and interviews with staff and Physician Assistant, the facility failed to follow the plan of care for 2 staff members to assist with activities for daily living (ADL) for 1 of 4 residents (Resident #25) whose care plans were reviewed.

Inspectors wroteBased on observations, record review, and staff and resident interviews, the facility failed to provide supervision to Resident #44, a severely cognitively impaired resident, who was inadvertently let out of the facility by some visiting children, who held the front door open preventing the wander guard system from locking the door, and she exited the building. The resident was outside without staff knowledge for approximately 5 minutes, where she self-propelled her wheelchair to the curb cut for wheelchairs leading to the parking lot, and overturned hitting her head, resulting in her having to be transported by emergency medical services (EMS) to the emergency department for evaluation and treatment. This deficient practice was identified for 1 of 4 residents reviewed for supervision to prevent accidents.

Inspectors wroteBased on record review, observations, and staff and resident interviews, the facility failed to provide nutritional supplements to 1 of 11 residents reviewed for nutrition ( Resident #89).

Inspectors wroteBased on observations, record review, and staff and resident interviews, the facility failed to honor food preferences for 1 of 12 residents reviewed for nutrition (Resident # 76) reviewed for meal preferences.

Inspectors wroteBased on observations and interviews with staff and residents, the facility failed to provide a clean, homelike environment for 4 resident rooms on 2 of 5 halls reviewed for the environment (200 hall and 300 hall).

Inspectors wroteBased on record review, and staff and Nurse Practitioner interviews the facility failed to assess Resident #4 before transferring her back to bed after she was found on the floor for 1 of 2 residents reviewed for falls.

Inspectors wroteBased on observations, record review, staff, and the Physician Assistant interviews the facility failed to notify the physician of a residents change in condition and transport to the hospital for 1 of 1 resident (Resident #1) reviewed for hospitalization.

Inspectors wroteBased on observations, record review, staff, and the Physician Assistant interviews the facility failed to hold a short acting insulin as ordered by the physician for blood sugar readings less than 120 mg/dl (milligrams per deciliter). This resulted in the resident receiving 20 additional units of insulin. There was no significant outcome related to the insulin administration. This occurred for 1 of 1 resident (Resident #1) reviewed for medication administration.

Inspectors wroteBased 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).

Inspectors wroteBased on observation and staff interviews the facility failed to: 1) maintain sanitizing solutions used in the kitchen at the strength recommended by the manufacturer; 2) maintain a clean and sanitized kitchen area for food preparation; and 3) ensure refrigerated items were sealed and labeled. These practices had the potential to affect food quality and kitchen sanitation safety.

Inspectors wroteBased on observations, record review and Physician Assistant and staff interviews, the facility's Quality Assurance and Performance Improvement Program (QAPI) failed to maintain implemented procedures and monitor interventions that the committee put into place following a recertification and complaint investigation of 04/15/21 for three deficiencies that were originally cited in area of quality of care (F684), dietary services (F812) and infection control (880). These deficiencies were subsequently recited on the current recertification and complaint survey of 01/12/24. The continued failure during a previous survey of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to implement a care planned intervention by not placing a fall mat at the bedside for a resident with a history of falls (Resident #90). This occurred for 1 of 6 residents reviewed for accidents.

Inspectors wroteBased on record review, staff interviews, and the Physician Assistant's interview the facility failed to implement a process to maintain ongoing communication and collaboration with the dialysis facility to share necessary information on the resident's condition before and after dialysis treatments . This occurred for 1 of 1 resident (Resident #22) reviewed for dialysis care.

Inspectors wroteBased on record review, family and staff interviews the facility failed to ensure a resident attended an outside medical appointment since February 2023 regarding the treatment of rheumatoid arthritis for 1 of 1 sampled resident reviewed for medically related social services (Resident #20).

Inspectors wroteBased on record review, staff interviews, and hospice staff interviews the facility failed to maintain communication and coordination of services provided by hospice in the medical record complete with hospice admission documentation, hospice plan of care, and hospice visit notes in the facility's electronic medical record and failed to obtain physician orders for hospice services for 3 of 3 residents reviewed for hospice, (Resident #60, Resident #59, and #73).

Inspectors wroteBased on record review and staff interviews, the facility failed to prevent the misappropriation of a resident's controlled medication, (60 Oxycodone/Acetaminophen 5-325 milligrams (mg) pills), which were prescribed by the physician for pain for 1 of 1 resident reviewed for misappropriation of property (Resident #97).

Inspectors wroteBased on observations, record review and staff and Physician Assistant interviews, the facility failed to assess and implement treatments to two skin impairment areas for 1 of 1 resident (Resident #73) observed.

Inspectors wroteBased on record review, observation, and interviews with the Physician Assistant (PA), Responsible Party (RP), resident, and staff, the facility failed to facilitate an optometrist appointment for 1 of 1 resident reviewed for vision (Resident #20).

Inspectors wroteBased on observations, record review and staff and Physician Assistant interviews, the facility failed to perform daily skin assessments to assess for any signs or symptoms of a scabies infection on a resident (Resident #73) who was sharing a room with another resident (Resident #3) who had an active diagnoses of scabies and was on isolation precautions for 1 of 9 residents reviewed for infection control. This had the potential to affect all facility residents.

Inspectors wroteBased on record reviews, residents, family members, and staff interviews the facility failed to ensure the Resident's right to file a grievance and receive a written decision regarding the grievance investigation. This occurred for 4 of 4 residents reviewed for the grievance process (Residents #30, #59, #45, and #52).

Inspectors wroteBased on record review, staff interviews, and the Regional Ombudsman interview the facility failed to notify the Regional Ombudsman in writing when 2 of 2 sampled residents were discharged to the hospital (Resident #92, Resident #248).