Kerr Lake Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Kerr Lake Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 1, 2024

  Based on record review and interviews with staff, Responsible Party (RP), Medical Director, Poison Control Center, and Hospital Physician, the facility failed to provide a safe environment to prevent an avoidable accident for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 had severe cognitive impairment, was dependent on staff for assistance, and was allergic to ingredients that were commonly found in shampoos, skin care products, and soap. On [DATE] Resident #1 had access to a bar of soap (Soap #1), she ingested the soap, and had an allergic reaction which included mouth and lip swelling and was transferred to the Emergency Department (ED) for further treatment. […]

• Immediate jeopardy, isolatedF689Mar 28, 2023

  Based on staff interviews, Physician interview, observation, and record review, the facility failed to provide incontinent care safely for a resident who required extensive staff assistance for 1 (Resident #1) of 3 residents reviewed for accidents. On 3/22/23 during incontinent care provided by Nursing Assistant (NA) #1, Resident #1 rolled off of the bed hitting her face on the nightstand and landing on the floor. Resident #1 sustained bruises to all extremities and the left side of her face, a laceration on left forehead 0.5 centimeters (cm) in length, multiple skin tears to her upper right arm, fractures of the left and right distal femurs (fracture of the thigh bone that occur just above the knee joint), a right lateral tibia plateau fracture (a break of the larger lower leg bone below… […]

• No harm, potential for more than minimal, widespreadF908Apr 21, 2022

  Based on record review, observations and staff interviews the facility failed to maintain the dish machine in safe operating condition for 71 of 71 residents. The findings included: The Installation, Operation, and Service Manual for the dishwasher was reviewed. It stated the minimum water requirements were wash and rinse temperatures of 120 degrees Fahrenheit (F). An observation on 4/18/21 at 10:29 AM was made of the dish machine in the kitchen, the wash cycle gauge read 110 degrees F after 5 run cycles with the Dietary Manager (DM) present. He stated the gauge might have been broken, and most of the dishes were washed by hand in the 3-part sink. […]

• No harm, potential for more than minimal, patternF812Feb 12, 2026

  Based on observations and staff interviews, the facility failed to keep food service equipment clean, free of grease buildup, and/or dried spills by failing to clean the convection oven during two kitchen observations. This practice had the potential to affect food served to the residents who resided in the facility.The findings included:Review of the undated /blank Weekly Deep Cleaning Schedule, sixth line down, indicated/listed Convection Ovens were included to be cleaned.Review of the Dietary Sanitation Checklist dated 12/23/25 completed by the Dietitian documented the kitchen equipment had been cleaned.Review of the Dietary Sanitation Checklist dated 1/28/26 completed by the Dietitian showed no documentation the kitchen equipment had been cleaned.During a kitchen tour on 2/09/26 at… […]

• No harm, potential for more than minimal, patternF756Nov 6, 2024

  Based on record review, staff interview and Consultant Pharmacist interview, the Consultant Pharmacist failed to identify and report a medication irregularity on 7 Monthly Medication Reviews when Dyskinesia Identification System Condensed User Scale (DISCUS) assessments (used for medication monitoring of side effects of antipsychotic medication) were not completed for a resident who received Risperdal, Haloperidol and Olanzapine (antipsychotic medications). The Consultant Pharmacist also failed to identify and address an order for as needed (PRN) Haloperidol that extended beyond the 14-day limit for 1 of 6 residents reviewed for unnecessary medications. (Resident #57) The findings included: 1. […]