Cycle 1
Health 2024-11-06 · Fire 2024-11-06
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Henderson, NC
Kerr Lake Nursing and Rehabilitation Center
3-star overall rating with 3-star inspections with $32,269 in total fines with 2 recent health deficiencies
1245 Park Avenue, Henderson, NC
(252) 492-7021
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
92
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Principle Long Term Care
Operator or chain grouping
Approved since
1990-07-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
44 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.16
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.89
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,466
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.08
Composite VBP score used to determine payment impact.
Payment multiplier
0.9896
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.43
Baseline 19.65% · Performance 19.84% · Measure score 3.43 · Achievement 3.43 · Improvement 0
Healthcare-associated infections
0.35
Baseline 9.00% · Performance 8.66% · Measure score 0.35 · Achievement 0 · Improvement 0.35
Total nurse turnover
7.64
Baseline 55.32% · Performance 32.47% · Measure score 7.64 · Achievement 7.64 · Improvement 7
Adjusted total nurse staffing
3.02
Baseline 4.02 hours · Performance 3.94 hours · Measure score 3.02 · Achievement 3.02 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.7% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 123 · Observed rate 16.26% · Lower 95% interval 8.72% |
| Discharge to community | 52.27% |
50.57%
1.7 pts better
|
No Different than the National Rate · Eligible stays 128 · Observed rate 44.53% · Lower 95% interval 43.9% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 98 · Denominator 98 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 2 · Denominator 98 |
| Discharge self-care score | 44.59% |
53.69%
9.1 pts worse
|
Numerator 33 · Denominator 74 |
| Discharge mobility score | 31.08% |
50.94%
19.9 pts worse
|
Numerator 23 · Denominator 74 |
| Pressure ulcers or injuries, new or worsened | 3.06% |
2.29%
0.8 pts worse
|
Numerator 3 · Denominator 98 · Adjusted rate 2.71% |
| Healthcare-associated infections requiring hospitalization | 8.66% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 10.98% · Lower 95% interval 5.75% |
| Staff COVID-19 vaccination coverage | 1.98% |
8.2%
6.2 pts worse
|
Numerator 2 · Denominator 101 |
| Staff flu vaccination coverage | 15.27% |
42%
26.7 pts worse
|
Numerator 20 · Denominator 131 |
| Discharge function score | 45.95% |
56.45%
10.5 pts worse
|
Numerator 34 · Denominator 74 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 69 · Denominator 69 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 30.43% |
25.2%
5.2 pts better
|
Numerator 14 · Denominator 46 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.9 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.4% |
91.5%
1.1 pts worse
|
93.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.7% · Q2 84.6% · Q3 96.3% · Q4 94.4% · 4Q avg 90.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.6%
2.2 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
4.8%
2.2 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 6.0% · Q4 2.1% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
7.2%
0.4 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 12.5% · Q3 3.9% · Q4 3.8% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.4% |
21.6%
5.2 pts better
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 16.0% · Q3 17.3% · Q4 13.5% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.7% |
15.0%
5.3 pts better
|
16.7%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 9.1% · Q3 10.4% · Q4 8.9% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.4% |
16.8%
1.4 pts better
|
14.9%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 18.6% · Q3 8.5% · Q4 15.6% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
2.6%
1.6 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.7% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.2% |
21.2%
12 pts better
|
19.8%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 5.0% · Q3 11.5% · Q4 11.8% · 4Q avg 9.2% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
6.0%
0.9 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.5% · Q3 9.3% · Q4 7.7% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.5% |
79.9%
1.4 pts worse
|
81.7%
3.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.2% · Q2 73.2% · Q3 80.2% · Q4 90.1% · 4Q avg 78.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.8% |
13.2%
1.6 pts worse
|
12.0%
2.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.8% · Observed 13.9% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.5%
0.3 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.5% · Q3 0.0% · Q4 1.5% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.4% |
78.1%
4.3 pts better
|
79.7%
2.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.1% |
22.9%
7.8 pts better
|
23.9%
8.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 16.5% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-23 · Fire 2023-08-23
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2022-04-21 · Fire 2022-04-21
3 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-08-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-08-23
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-11-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-06
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-11-06
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-12-04
J · Immediate jeopardy
2024-05-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-05-01
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-05-24
D · Potential for more than minimal harm
2023-08-23
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-23
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-13
J · Immediate jeopardy
2023-03-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-25
F · Potential for more than minimal harm
2022-04-21
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-05-16
D · Potential for more than minimal harm
2022-04-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-05-16
Penalties and ownership
What sits behind the stars
$19,620
2024-05-01
Fine
Fine · fine $19,620
Fine
$12,649
2023-03-28
Fine
Fine · fine $12,649
Fine
Ownership
Principle It Services, Inc.
5% Or Greater Direct Ownership Interest · Organization
Principle Long Term Care, Inc.
5% Or Greater Direct Ownership Interest · Organization
Hill, Robert
5% Or Greater Indirect Ownership Interest · Individual
Hill, Stephen
5% Or Greater Indirect Ownership Interest · Individual
Hill, Raymond
5% Or Greater Indirect Ownership Interest · Individual
Boice, Gale
Corporate Officer · Individual
Hill, Raymond
Operational/Managerial Control · Individual
Hill, Robert
Operational/Managerial Control · Individual
Hill, Stephen
Operational/Managerial Control · Individual
Hughes, Nancy
Operational/Managerial Control · Individual
Hughes, Nancy
W-2 Managing Employee · Individual
Johnson, Dianne
Corporate Director · Individual
Principle Long Term Care, Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Camellia Gardens Center for Nursing and Rehab
Henderson, NC
1-star overall rating with 1-star inspections with $74,576 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Senior Citizens Home
Henderson, NC
2-star overall rating with 2-star inspections with $55,760 in total fines with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Brantwood Nh & Retirement Center
Oxford, NC
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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