Cycle 1
Health 2025-08-28 · Fire 2024-07-11
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Kannapolis, NC
Big Elm Retirement and Nursing Centers
2-star overall rating with 2-star inspections with $15,873 in total fines with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1285 West A Street, Kannapolis, NC
(704) 932-0000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.56
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.34
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.78
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.14
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
5.13
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,825
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9955
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.29
Baseline 20.12% · Performance 19.44% · Measure score 4.29 · Achievement 4.29 · Improvement 1.68
Healthcare-associated infections
2.06
Baseline 6.87% · Performance 7.22% · Measure score 2.06 · Achievement 2.06 · Improvement 0
Total nurse turnover
0.66
Baseline 50.00% · Performance 60.98% · Measure score 0.66 · Achievement 0.66 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5.73 hours · Performance 6.34 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.96% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 7.41% · Lower 95% interval 6.61% |
| Discharge to community | 42.73% |
50.57%
7.8 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 35.06% · Lower 95% interval 32.01% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 65 · Denominator 65 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 65 |
| Discharge self-care score | 69.05% |
53.69%
15.4 pts better
|
Numerator 29 · Denominator 42 |
| Discharge mobility score | 59.52% |
50.94%
8.6 pts better
|
Numerator 25 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 7.69% |
2.29%
5.4 pts worse
|
Numerator 5 · Denominator 65 · Adjusted rate 5.86% |
| Healthcare-associated infections requiring hospitalization | 7.22% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 7.69% · Lower 95% interval 3.97% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 152 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 76.19% |
56.45%
19.7 pts better
|
Numerator 32 · Denominator 42 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | 93.94% |
96.28%
2.3 pts worse
|
Numerator 31 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 12.5% |
25.2%
12.7 pts worse
|
Numerator 3 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
91.5%
6 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.5% · Q3 97.6% · Q4 95.2% · 4Q avg 97.5% |
| 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 | 4.4% |
3.6%
0.8 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 4.8% · Q4 9.5% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 21.2% |
4.8%
16.4 pts worse
|
11.4%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 25.6% · Q3 23.1% · Q4 22.5% · 4Q avg 21.2% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
7.2%
3.1 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 0.0% · Q3 2.6% · Q4 7.9% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.1% |
21.6%
4.5 pts worse
|
19.6%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 17.9% · Q3 33.3% · Q4 30.0% · 4Q avg 26.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.2% |
15.0%
4.2 pts worse
|
16.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 16.7% · Q3 18.8% · Q4 25.0% · 4Q avg 19.2% · 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 ability to walk independently worsened | 27.0% |
21.5%
5.5 pts worse
|
16.3%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 10.9% · Q3 21.8% · 4Q avg 27.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.6% |
16.8%
6.8 pts worse
|
14.9%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 20.0% · Q3 30.8% · Q4 19.4% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
0.9%
1.7 pts worse
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.2% · Q3 3.4% · Q4 1.8% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 10.6% |
2.6%
8 pts worse
|
1.7%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 5.4% · Q3 15.4% · Q4 12.5% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.6% |
21.2%
12.4 pts worse
|
19.8%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 28.1% · Q3 33.7% · Q4 38.2% · 4Q avg 33.6% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
6.0%
3.2 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.6% · Q3 2.2% · Q4 3.4% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
79.9%
12.4 pts better
|
81.7%
10.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.8% · Q2 93.8% · Q3 95.0% · Q4 90.6% · 4Q avg 92.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.7% |
13.2%
4.5 pts better
|
12.0%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.7% · Observed 9.3% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.8% |
1.5%
3.3 pts worse
|
1.6%
3.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 4.3% · Q3 8.3% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.3% |
78.1%
8.2 pts better
|
79.7%
6.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
22.9%
0.9 pts worse
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 25.9% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-11 · Fire 2023-03-29
5 health deficiencies
Top issue: Resident Rights (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-29 · Fire 2021-10-29
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-07-11
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-09-22
D · Potential for more than minimal harm
2024-07-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-22
D · Potential for more than minimal harm
2024-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-22
D · Potential for more than minimal harm
2024-07-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-22
D · Potential for more than minimal harm
2024-07-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-22
D · Potential for more than minimal harm
2024-07-11
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-09-22
D · Potential for more than minimal harm
2024-07-11
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-09-22
D · Potential for more than minimal harm
2024-07-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-22
F · Potential for more than minimal harm
2023-03-29
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-06-25
D · Potential for more than minimal harm
2023-03-29
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2023-06-25
D · Potential for more than minimal harm
2023-03-29
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-06-25
D · Potential for more than minimal harm
2023-03-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-25
D · Potential for more than minimal harm
2023-03-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-25
D · Potential for more than minimal harm
2023-03-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-25
D · Potential for more than minimal harm
2023-03-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-25
E · Potential for more than minimal harm
2021-10-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-28
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-09-22
D · Potential for more than minimal harm
2025-08-28
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 2025-09-22
D · Potential for more than minimal harm
2025-08-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-22
B · Minimal harm
2025-08-28
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-09-22
F · Potential for more than minimal harm
2024-07-11
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 2024-08-04
D · Potential for more than minimal harm
2024-07-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-04
D · Potential for more than minimal harm
2024-07-11
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 2024-08-04
C · Minimal harm
2024-07-11
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-08-04
B · Minimal harm
2024-07-11
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-08-04
L · Immediate jeopardy
2023-03-29
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-03-29
E · Potential for more than minimal harm
2023-03-29
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 2023-03-29
E · Potential for more than minimal harm
2023-03-29
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-03-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-29
E · Potential for more than minimal harm
2023-03-29
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-03-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-29
B · Minimal harm
2023-03-29
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-03-29
Penalties and ownership
What sits behind the stars
$15,873
2023-03-29
Fine
Fine · fine $15,873
Fine
Ownership
Ennis, Ann
W-2 Managing Employee · Individual
Gatewood, Thomas
5% Or Greater Direct Ownership Interest · Individual
Gatewood, Thomas
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Kannapolis Health and Rehabilitation
Kannapolis, NC
1-star overall rating with 1-star inspections with $133,864 in total fines with 8 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#2
The Greens at Cabarrus
Concord, NC
5-star overall rating with 4-star inspections with $15,269 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Five Oaks Rehabilitation and Care Center
Concord, NC
1-star overall rating with 1-star inspections with $17,345 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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