Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Senior Citizens Home during CMS and state inspections, most recent first.
The facility failed to maintain clean HVAC vents in the kitchen, where two of three vents located above a food preparation table holding wrapped silverware were observed with dark debris on the metal surfaces. On a follow-up observation, the vents remained in the same condition while the air system was operating and blowing toward the tray line. The CFM reported that HVAC filters were not on the kitchen cleaning schedule and that Maintenance handled vent cleaning every one to two months but could not specify when it was last done. The Maintenance Director stated that a change in company ownership resulted in the removal of automated reminders from the work order software, and he believed the corroded filters were original and could not recall the last cleaning.
A resident with COPD, depression, and bipolar disorder did not receive multiple doses of newly ordered Divalproex, Olanzapine, and Trelegy Ellipta after admission because the medications were never obtained from the pharmacy. Over several days, nurses documented on the MAR that these medications were not administered and repeatedly noted they were "on order," with one nurse acknowledging she did not check the Pyxis and did not contact the family for a home supply. Staff believed administrative nurses had ordered the medications and that orders would transmit electronically to the new pharmacy as with the prior system, but the pharmacy later confirmed it did not receive faxed orders for these drugs until several days after they were written, during which time the resident went without the prescribed anticonvulsant, antipsychotic, and triple-therapy bronchodilator.
A resident with COPD and bipolar disorder did not receive newly ordered Divalproex, Olanzapine, and Trelegy Ellipta for several days because the medications were not available and remained "on order" from the pharmacy. Multiple nurses documented on the MAR that these medications were not administered on several consecutive days, citing that they were on order. The resident reported lacking his inhaler and some other medications for the first few days after admission. A nurse practitioner documented that the resident had missed doses of Trelegy, Valproic Acid, and Olanzapine and stated that interruption of these medications could cause mood instability, increased behaviors, and breathing issues, and that the medications should have been administered as ordered.
The facility's assessment lacked input from direct care staff and residents, and failed to evaluate contracted services for essential care. The staffing plan did not address specific shift needs or changes in resident population, potentially affecting all 49 residents.
The facility failed to submit accurate PBJ data to CMS for Q3 2024, missing RN hours and 24-hour licensed nursing coverage on specific dates. The Human Resources Manager submitted incomplete data due to delays in receiving agency staff information, assuming corrections would be made later. The Administrator confirmed the presence of required staff, indicating a reporting error.
The facility failed to conduct quarterly reviews of care plans for five residents, resulting in outdated care plans. Residents with conditions such as COPD, diabetes, and dementia had their last reviews in mid-2024, with no updates since. The DON, also serving as the MDS Nurse, acknowledged the backlog, while the Administrator was initially unaware of the issue.
The facility inaccurately coded MDS assessments for two residents, leading to deficiencies in falls and restraints. One resident's fall with a major injury was not recorded, while another resident's bed rails, used for mobility, were incorrectly coded as restraints. These errors were acknowledged by the MDS Nurse and DON.
A facility failed to document a physician order for dialysis for a resident with end-stage renal disease. The resident was admitted with a hospital discharge summary that included dialysis instructions, but the Unit Manager omitted entering the order in the medical record. Interviews revealed that staff were aware of the resident's dialysis needs, but the order was not transcribed, as confirmed by the DON and Administrator.
The facility failed to post accurate nurse staffing data for 18 days, with discrepancies between the Daily Nursing Staffing Forms and actual staffing levels. The Scheduler admitted to errors, and the new DON was unaware of the inaccuracies, highlighting a lack of oversight in the staffing data process.
Unsanitary Kitchen HVAC Vents Above Food Preparation Area
Penalty
Summary
The facility failed to maintain kitchen HVAC equipment in a clean and sanitary condition, resulting in two of three HVAC vents located approximately two feet above a food preparation table, where wrapped silverware was stacked for lunch service, being observed with dark debris on the metal vents. During an initial kitchen tour with the Certified Food Manager, the air filter system was off, yet the debris was visible on the vents above the prep table. A subsequent observation the following day found the kitchen filters in the same condition, with dark debris still present on the vents while the air filter system was on and blowing air toward the tray line located about six feet away, although the tray line was not in use at that time. In interviews, the Certified Food Manager stated that the HVAC filters were not included on the kitchen cleaning schedule and that Maintenance came in every one to two months to clean the vents, but she was unsure when the filters had last been cleaned. The Maintenance Director reported that after a recent change in company ownership, the automated reminder to clean the kitchen vents was no longer appearing in the facility’s work order software, and he believed the filters appeared original with corrosion and could not recall when he last cleaned the vents. The Administrator acknowledged the condition of the HVAC filters during interview.
Failure to Obtain and Administer Ordered Psychotropic and COPD Medications After Pharmacy Transition
Penalty
Summary
The deficiency involves the facility’s failure to ensure the acquiring, dispensing, and administration of ordered medications for one resident, resulting in multiple missed doses of an anticonvulsant, an antipsychotic, and a COPD maintenance inhaler. The resident was admitted with diagnoses including COPD, depression, and bipolar disorder and had new physician orders initiated for Divalproex Sodium 1000 mg at bedtime for bipolar disorder, Olanzapine 2.5 mg at bedtime for bipolar disorder, and Trelegy Ellipta one puff daily for COPD. Medication Administration Records (MARs) for several days showed these medications were not administered, with chart codes referencing progress notes that documented the medications were still on order rather than available for use. For Divalproex Sodium, the MAR documented that the medication was not given on two separate days, and nursing notes on those days stated the medication was on order. For Olanzapine, the MAR showed it was not administered on three days, with corresponding notes from two different nurses indicating the medication was on order each time. For Trelegy Ellipta, the MAR documented it was not administered over four consecutive days, with multiple nursing notes stating the inhaler was on order and one health status note indicating the on-call provider was notified that the facility was still awaiting delivery of the medication. On one of the days Trelegy was not administered, there was no corresponding medication administration note in the electronic record. Interviews revealed that nursing staff were aware that the resident had not received all ordered medications after admission and believed medications had been ordered by administrative nurses and were pending delivery from the pharmacy. One nurse acknowledged not checking the Pyxis for availability of medications and did not contact the resident’s family to see if there was a home supply. The DON stated the facility had recently switched to a new pharmacy and believed orders would transmit electronically as with the prior system, and that the facility was not aware the resident’s medication orders had not been transmitted. Pharmacy staff reported that the orders for the resident’s Divalproex, Olanzapine, and Trelegy were not actually received until several days after the orders were written, at which time the medications were delivered, confirming that the medications had not been available during the period they were documented as “on order.”
Missed Psychotropic and COPD Medications Due to Pharmacy Ordering Failure
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when multiple newly ordered medications were not administered over several days because they were not available from the pharmacy. The resident was admitted with COPD, depression, and bipolar disorder and had new physician orders initiated for Divalproex Sodium 1000 mg at bedtime for bipolar disorder, Olanzapine 2.5 mg at bedtime for bipolar disorder, and Trelegy Ellipta one puff daily for COPD. Medication Administration Records (MARs) for several days in February showed these medications were not given, with chart codes referencing progress notes that documented the medications were “on order.” For Divalproex Sodium, the February MAR showed missed doses on two separate days by the same nurse, who documented in medication administration notes that the medication was on order and therefore not administered. For Olanzapine, the MAR showed missed doses on three consecutive days by two different nurses, each documenting in medication administration notes that the medication was on order and not available to administer. For Trelegy Ellipta, the MAR showed missed doses on four consecutive days by three different nurses, with notes on three of those days stating the medication was on order; there was no corresponding medication administration note for one of the missed days. Nursing documentation also showed the resident was on 2 L/min oxygen via nasal cannula with even, unlabored respirations during this period. Interviews confirmed that nursing staff did not administer the Divalproex Sodium, Olanzapine, and Trelegy Ellipta because the medications had not arrived from the pharmacy and were considered to be on order. The resident reported that he did not have his inhaler and a couple of other medications when he first arrived and that it took a few days before he received all of his medications. A nurse practitioner progress note documented that the resident was seen for a follow-up visit related to missing medications and that he had missed doses of Trelegy, Valproic Acid, and Olanzapine after admission. The nurse practitioner stated that interruption of Depakote and Olanzapine could cause mood instability and increased behaviors, and omission of Trelegy could cause increased breathing issues, and that the medications should have been administered as ordered.
Deficiency in Facility Assessment and Staffing Plan
Penalty
Summary
The facility failed to ensure the involvement of required parties in developing the Facility Assessment, which is crucial for determining necessary resources for resident care during both regular operations and emergencies. The assessment was revised and updated multiple times, but it lacked input from direct care staff, residents, resident representatives, and family members. This oversight in collaboration could potentially affect the quality of care provided to all 49 residents in the facility. Additionally, the Facility Assessment did not evaluate contracted services for medical supplies, ambulance, emergency services, and dialysis, which are essential for resident care. The staffing plan outlined the desired number of FTEs for nurses and CNAs but failed to address specific staffing needs for each shift, weekends, or changes in the resident population. The Administrator, who was not present during the implementation of the new process, did not update or review the assessment, indicating a lack of oversight and comprehensive planning.
Inaccurate PBJ Data Submission Due to Incomplete Payroll Information
Penalty
Summary
The facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) for the third quarter of the fiscal year 2024. Specifically, the PBJ report lacked Registered Nurse (RN) hours for certain dates and did not reflect 24-hour licensed nursing coverage on other specified dates. Upon review, it was found that the facility did have RN hours and 24-hour licensed nursing coverage for those dates, as evidenced by the Posted Daily Nursing Staffing Forms, Daily Staffing Sheet, and nursing staff time detail reports. The Human Resources Manager, responsible for entering nursing hours into the payroll system, admitted to submitting incomplete data to the corporate office due to delays in receiving information from agency staff. She updated the payroll system once the information was received, assuming the PBJ reports would be corrected and resubmitted. The Administrator confirmed that the PBJ data was submitted based on the information entered by the Human Resources Manager and acknowledged the presence of RN hours and licensed nursing staff as required, suggesting an error occurred during data reporting.
Failure to Conduct Timely Care Plan Reviews
Penalty
Summary
The facility failed to conduct quarterly reviews of resident care plans for five residents, leading to deficiencies in maintaining up-to-date care plans. Resident #23, who was admitted with chronic obstructive pulmonary disease and osteoarthritis, had their last care plan review on 7/30/24, with no subsequent updates. Similarly, Resident #6, diagnosed with diabetes, chronic kidney disease, and stroke, had their care plan last reviewed on 5/23/24. Both residents were found to be cognitively intact during their Minimum Data Set (MDS) assessments. The Director of Nursing (DON), who also served as the MDS Nurse, acknowledged the overdue reviews and was aware of the backlog in care plan updates. Additional residents, including Resident #9 with heart disease and atrial fibrillation, Resident #8 with dementia and atrial fibrillation, and Resident #45 with diabetes and a history of stroke, also had outdated care plans. The last reviews for these residents were conducted in July 2024, with no further updates. Resident #8 and Resident #45 were noted to be severely cognitively impaired. Interviews with the DON confirmed the overdue status of these care plans, and the facility's Administrator expressed an expectation for timely reviews and updates, although she was initially unaware of the issue.
Inaccurate MDS Coding for Falls and Restraints
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the areas of falls and restraints. Resident #45, who was admitted with osteoarthritis, dementia, and a history of stroke, experienced a fall resulting in a major injury. However, the MDS assessment inaccurately indicated that there were no falls since admission. This error was acknowledged by the MDS Nurse and the Director of Nursing (DON), who confirmed that the assessment should have been coded for one fall with a major injury. Resident #23, who was cognitively intact, had an active physician order for 1/4 bed rails to assist with bed mobility. The MDS assessment incorrectly coded these side rails as physical restraints used daily. Observations and interviews confirmed that the side rails were used by the resident for mobility and should not have been coded as restraints. The MDS Nurse and the DON both recognized the coding error, indicating a failure to ensure accurate resident assessments.
Failure to Document Physician Order for Dialysis
Penalty
Summary
The facility failed to have a physician order for dialysis in the medical record for a resident who required such services. The resident, diagnosed with end-stage renal disease stage 5, was admitted to the facility with a hospital discharge summary that included dialysis instructions. However, the Unit Manager, responsible for admitting the resident, omitted entering the physician order for dialysis in the medical record. During interviews, both the Unit Manager and a nurse acknowledged the absence of the order, despite being aware that the resident received dialysis. The Director of Nursing confirmed that it was the admission nurse's responsibility to ensure physician orders were entered, and the Administrator reiterated that nursing staff should have transcribed the orders from the hospital discharge summary.
Inaccurate Nurse Staffing Data Posting
Penalty
Summary
The facility failed to post accurate licensed nurse staffing data for 18 out of 30 days reviewed. The discrepancies were found in the Daily Nursing Staffing Forms for various shifts throughout the month. For the 7:00 am-3:00 pm shift, there were multiple instances where the number of Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) recorded on the Daily Nursing Staffing Form did not match the actual staffing numbers on the Daily Staffing Sheet. Similar inaccuracies were noted for the 3:00 pm-11:00 pm and 11:00 pm-7:00 am shifts, where the recorded staffing levels often showed fewer RNs and LPNs than were actually present according to the Daily Staffing Sheet. Interviews with facility staff revealed that the Scheduler used a staffing template to complete the Daily Staffing Form and admitted to missing the days where the staffing was recorded incorrectly. The Director of Nursing (DON), who was new to the facility, was unaware of the inaccuracies in the Daily Staffing Forms and had not previously checked them for accuracy. The DON stated that the Scheduler should verify the information before posting it, indicating a lack of oversight and verification in the staffing data recording process.
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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) |
|---|---|---|---|---|
| Kerr Lake Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 2 | 0 |
| Camellia Gardens Center For Nursing And Rehab | 2.9 mi | ★★★★★ | 7 | 1 |
| Brantwood Nh & Retirement Center | 7.8 mi | ★★★★★ | 2 | 0 |
| Oxford Health And Rehabilitation Center | 8.1 mi | ★★★★★ | 14 | 0 |
| Louisburg Healthcare & Rehabilitation Center | 16 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.