Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Kerr Lake Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that convection ovens in the dietary department were not being cleaned as required, despite a deep cleaning schedule and sanitation checklist indicating they should be maintained. During two separate kitchen observations, the double-stacked ovens were noted to have heavy grease buildup on interior surfaces, doors, and seals, along with charred food particles on a shelf, with no documented cleaning on a more recent sanitation checklist. The Dietary Manager acknowledged the ovens were usually cleaned weekly but appeared not to have been cleaned for some time, creating a potential impact on food served to residents.
A cognitively intact resident with chronic pain had three Oxycodone 5 mg blister cards delivered and signed in by nursing staff. A medication aide and an RN counted 27 controlled substance cards at one shift change, including the resident’s Oxycodone. By the next shift change, an RN and another nurse found that one Oxycodone card containing 30 tablets for this resident was missing, with 27 narcotic count sheets but only 26 corresponding cards. The unit manager verified the discrepancy, and a full audit of all med carts and storage areas failed to locate the missing card. The pharmacist confirmed no return of this Oxycodone to the pharmacy, and the facility was unable to determine how the narcotic card was lost, resulting in misappropriation of the resident’s medication.
A Consultant Pharmacist failed to identify and report medication irregularities for a resident on antipsychotic medications, neglecting to recommend necessary DISCUS assessments and allowing a PRN Haloperidol order to extend beyond the 14-day limit without reevaluation. The resident, with severe cognitive impairment, did not receive the required monitoring for side effects, and the oversight was confirmed by the pharmacist, DON, and Medical Director.
A facility failed to conduct required DISCUS assessments for a resident on antipsychotic medications and did not limit PRN antipsychotic orders to 14 days. The resident, with severe cognitive impairment, received PRN Haloperidol beyond the required duration without reevaluation. Another resident was prescribed Xanax without a 14-day stop date, contrary to regulations. Interviews confirmed the necessity of these protocols, but they were not followed.
A resident with severe cognitive impairment and known allergies ingested a bar of soap, leading to a fatal allergic reaction. The facility failed to document and communicate the resident's allergies, resulting in inadequate supervision and the resident's death due to anaphylactic shock.
A facility failed to document a resident's allergies to cocamidopropyl betaine and chloroxylenol in the medical record, despite these being listed in the hospital discharge summary. Staff interviews revealed inconsistencies in awareness of the allergies, and the DON and Administrator acknowledged the oversight.
The facility's QAA Committee failed to maintain procedures and monitor interventions, leading to a resident with severe cognitive impairment ingesting soap and suffering fatal anaphylactic shock. Additionally, another resident sustained multiple injuries due to unsafe incontinent care.
Failure to Maintain Clean Convection Ovens in Dietary Department
Penalty
Summary
The facility failed to maintain clean food service equipment, specifically the double-stacked convection ovens, in accordance with professional standards. An undated Weekly Deep Cleaning Schedule listed convection ovens as items to be cleaned, and a Dietary Sanitation Checklist dated 12/23/25 completed by the Dietitian documented that kitchen equipment had been cleaned, while a subsequent checklist dated 1/28/26 showed no documentation that kitchen equipment had been cleaned. During a kitchen tour on 2/09/26 at 11:03 AM with the Dietary Manager, surveyors observed a large volume of grease buildup inside the convection ovens, including inside the doors and on the seals, as well as charred food particles on the bottom shelf of the top oven. A second observation on 2/12/26 at 8:45 AM revealed the ovens remained in the same condition. The Dietary Manager stated in an interview that the ovens were usually cleaned once a week but appeared not to have been cleaned in a while. This practice had the potential to affect food served to residents in the facility. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to environmental and sanitation practices in the dietary department that could impact all residents receiving food prepared in the kitchen.
Unresolved Misappropriation of a Resident’s Oxycodone Medication Card
Penalty
Summary
The facility failed to protect a resident’s belongings by not preventing the misappropriation of a narcotic medication, Oxycodone, prescribed for chronic pain. The cognitively intact resident had physician orders for Oxycodone 5 mg tablets, with directions to take 10 mg for moderate pain and 15 mg for severe pain as needed. Pharmacy records showed that three blister cards, each containing 30 tablets of Oxycodone 5 mg, were delivered and signed in by two nurses. At the time of the incident, the resident had additional Oxycodone cards available and had not missed any doses. On one evening shift, a medication aide working the day shift completed a controlled substance count with an RN at shift change, and they documented a total of 27 narcotic medication cards for residents on that hall, including the resident’s Oxycodone. The medication aide reported that the count was correct at that time and that she had not previously noticed missing narcotics on that cart. Later, during the next shift change between the night nurse and the oncoming nurse, the two nurses again counted the controlled medications and discovered that one Oxycodone card for the resident, containing 30 tablets, was missing. They noted that there were 27 controlled substance record sheets but only 26 corresponding medication cards. The unit manager verified the discrepancy by recounting the medications on the cart and confirmed that one Oxycodone card was missing when compared to the controlled substance count sheets. A 100% audit of all medication carts and medication storage rooms was conducted by the unit manager and the prior DON, and the missing Oxycodone card could not be located. The facility’s pharmacist later confirmed that no Oxycodone 5 mg for this resident had been returned to the pharmacy around the time of the loss. Interviews with staff and the resident confirmed that the resident continued to receive pain medication as needed, but the facility was unable to determine how the narcotic card was lost, resulting in an unresolved misappropriation of the resident’s medication.
Consultant Pharmacist Fails to Identify Medication Irregularities
Penalty
Summary
The Consultant Pharmacist failed to identify and report medication irregularities during the Monthly Medication Reviews for a resident who was prescribed antipsychotic medications, including Risperdal, Haloperidol, and Olanzapine. The resident, who was admitted with vascular dementia, generalized anxiety disorder, and a manic episode, did not have the required Dyskinesia Identification System Condensed User Scale (DISCUS) assessments completed to monitor for side effects of these medications. Despite multiple medication regimen reviews from April to October, no recommendations were made for the completion of DISCUS assessments, which are necessary to monitor for abnormal involuntary movements associated with long-term use of antipsychotic agents. Additionally, the Consultant Pharmacist did not address an order for as-needed (PRN) Haloperidol that extended beyond the 14-day limit, as required for PRN antipsychotic medications. The resident received Haloperidol on several occasions without reevaluation or a new order being written after the initial 14-day period. This oversight was confirmed during interviews with the Consultant Pharmacist, the Director of Nursing (DON), and the Medical Director, who all acknowledged the necessity of reevaluating PRN antipsychotic medications every 14 days. The failure to conduct DISCUS assessments and to adhere to the 14-day reevaluation requirement for PRN antipsychotic medications represents a significant oversight in the medication management process. The Consultant Pharmacist admitted that the resident had been overlooked and confirmed that recommendations for DISCUS assessments should have been made. The DON and the Administrator both expressed expectations that the Consultant Pharmacist would ensure DISCUS assessments were completed and that PRN antipsychotic medications were reviewed for appropriate stop dates or rationales for continued use.
Failure to Conduct DISCUS Assessments and Limit PRN Psychotropic Orders
Penalty
Summary
The facility failed to complete a Dyskinesia Identification System Condensed User Scale (DISCUS) assessment for a resident who was prescribed multiple antipsychotic medications. The resident, who was admitted with vascular dementia, generalized anxiety disorder, and a manic episode, had a DISCUS assessment conducted upon admission but not subsequently, despite changes in medication. The Consultant Pharmacist confirmed that the resident was overlooked for further DISCUS assessments, which should have been conducted upon medication changes and periodically. Additionally, the facility did not ensure that a PRN antipsychotic order for the same resident was limited to a 14-day duration. The resident received PRN Haloperidol beyond the 14-day period without reevaluation or a new order, as required. The Medical Director and Consultant Pharmacist both stated that PRN antipsychotic medications should be reevaluated every 14 days, and a new order should be written if continued use is necessary. Another resident was affected by the facility's failure to include a stop date for a PRN antianxiety medication order. The resident, who was severely cognitively impaired, was prescribed Xanax without a 14-day stop date. Interviews with the DON, Pharmacy Consultant, and Physician confirmed that PRN psychotropic medications should have a 14-day stop date, followed by reevaluation for continued use. The Physician could not explain why the order lacked a stop date, and the Administrator expected all PRN psychotropic medications to include a stop date.
Failure to Prevent Fatal Allergic Reaction
Penalty
Summary
The facility failed to provide a safe environment for a resident with severe cognitive impairment and known allergies to certain soap ingredients. The resident, who was dependent on staff for assistance, ingested a bar of soap containing allergens, leading to a severe allergic reaction. Despite being transferred to the emergency department and receiving medical interventions, the resident's condition continued to decline, ultimately resulting in death due to complications from anaphylactic shock. The incident occurred when a nurse aide found the resident with swollen lips and face, holding a bar of soap. The nurse administered an epinephrine injection and called for emergency services. Interviews with staff revealed that the resident had a history of placing non-food items in her mouth, but this behavior was not frequent. The staff were aware of the resident's allergies to erythromycin and perfume but did not consider soap as a potential allergen. Further investigation showed that the resident's allergy to specific soap ingredients was not documented in her medical records. The resident's responsible party had informed the facility multiple times about the soap allergy, but this information was not adequately communicated to all staff. The facility's failure to properly document and communicate the resident's allergies, combined with inadequate supervision, led to the resident's accidental ingestion of the soap and subsequent fatal allergic reaction.
Failure to Document Resident Allergies
Penalty
Summary
The facility failed to identify and document reported allergies in the medical record for a resident. The resident was admitted with a hospital discharge summary indicating allergies to cocamidopropyl betaine, chloroxylenol, and erythromycin. However, only the allergy to erythromycin was entered into the medical record, while the other two allergies were omitted. This oversight was discovered during a review of the resident's records and interviews with staff and the resident's responsible party (RP). Interviews with various staff members revealed inconsistencies in their awareness of the resident's allergies. Nurse #2 entered an intolerance to perfume into the electronic medical record but did not recall any other allergies being reported. Several nurse aides (NAs) were aware that the resident was to use only a specific soap (Soap #2) but were unclear if this was due to an allergy. The Medical Director confirmed that if allergies were listed on the hospital discharge record, they should have been documented in the medical record. The Director of Nursing (DON) and the Administrator acknowledged that the nurse responsible for the admission should have entered all allergies into the medical record. They were unable to explain why the allergies to cocamidopropyl betaine and chloroxylenol were not documented. The facility's normal process includes an admission audit tool checked by another nurse the next day, but this process failed to catch the omission in this case.
Failure to Prevent Accidents and Provide Safe Care
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions following a previous complaint investigation survey. This failure was evident in a recited deficiency related to providing supervision to prevent accidents. Specifically, a resident with severe cognitive impairment and allergies to common soap ingredients ingested a bar of soap, leading to an allergic reaction, intubation, mechanical ventilation, and ultimately death due to anaphylactic shock. The facility did not ensure a safe environment to prevent this avoidable accident. Additionally, during the same complaint investigation survey, the facility failed to provide safe incontinent care for another resident who required extensive staff assistance. This failure resulted in multiple injuries, including bruises, a laceration, skin tears, and fractures. The injuries caused significant pain to the resident's face and lower extremities. The Administrator revealed that the QAA committee had completed education and auditing for the previous deficiency but was unaware of the resident's prior behaviors of eating non-food items, which contributed to the incident.
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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 Henderson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Camellia Gardens Center For Nursing And Rehab | 1 mi | ★★★★★ | 7 | 1 |
| Senior Citizens Home | 2.4 mi | ★★★★★ | 3 | 0 |
| Brantwood Nh & Retirement Center | 9.9 mi | ★★★★★ | 2 | 0 |
| Oxford Health And Rehabilitation Center | 10.1 mi | ★★★★★ | 14 | 0 |
| Warren Hills Nursing Center | 15.6 mi | ★★★★★ | 13 | 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.