8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
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
1810 Concord Lake Road, Kannapolis, NC
(704) 933-3781
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
107
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Consulate Health Care/Independence Living Centers/Nspire Healthcare/Raydiant Health Care
Operator or chain grouping
Approved since
1987-04-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
36 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
RN hours / resident day
0.44
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.10
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.88
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
11,054
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.32% · Performance 21.62% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.37
Baseline 5.91% · Performance 6.53% · Measure score 4.37 · Achievement 4.37 · Improvement 0
Total nurse turnover
1.69
Baseline 57.14% · Performance 56.76% · Measure score 1.69 · Achievement 1.69 · Improvement 0
Adjusted total nurse staffing
1.21
Baseline 3.55 hours · Performance 3.42 hours · Measure score 1.21 · Achievement 1.21 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.21% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 5.81% · Lower 95% interval 6.41% |
| Discharge to community | 45.88% |
50.57%
4.7 pts worse
|
No Different than the National Rate · Eligible stays 84 · Observed rate 35.71% · Lower 95% interval 36.31% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 55 · Denominator 55 |
| Falls with major injury | 1.82% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 55 |
| Discharge self-care score | 34.15% |
53.69%
19.5 pts worse
|
Numerator 14 · Denominator 41 |
| Discharge mobility score | 31.71% |
50.94%
19.2 pts worse
|
Numerator 13 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 55 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.53% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 4.65% · Lower 95% interval 3.7% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 97 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 97 |
| Discharge function score | 36.59% |
56.45%
19.9 pts worse
|
Numerator 15 · Denominator 41 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.24% |
25.2%
8 pts worse
|
Numerator 5 · Denominator 29 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.3% |
91.5%
3.2 pts worse
|
93.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 77.3% · Q2 90.9% · Q3 97.2% · Q4 88.2% · 4Q avg 88.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 80.0% |
94.1%
14.1 pts worse
|
95.5%
15.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.6%
0.1 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.6% · Q3 7.0% · Q4 3.9% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
4.8%
3.3 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.5% · Q4 2.7% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 10.7% |
7.2%
3.5 pts worse
|
5.4%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 8.6% · Q3 16.2% · Q4 9.9% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.8% |
21.6%
2.2 pts worse
|
19.6%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 20.0% · Q3 29.4% · Q4 22.5% · 4Q avg 23.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.9% |
15.0%
0.1 pts better
|
16.7%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 12.1% · Q3 13.3% · Q4 20.0% · 4Q avg 14.9% · 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 | 17.1% |
21.5%
4.4 pts better
|
16.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q3 3.9% · Q4 14.7% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.3% |
16.8%
5.5 pts better
|
14.9%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 14.1% · Q3 14.1% · Q4 9.2% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
0.9%
2.1 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.4% · Q3 4.3% · Q4 1.9% · 4Q avg 3.0% · 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 1.3% · Q3 2.8% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
21.2%
2.1 pts worse
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.2% · Q2 23.6% · Q3 20.9% · Q4 13.7% · 4Q avg 23.3% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
6.0%
2 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.8% · Q3 3.4% · Q4 6.1% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 43.7% |
79.9%
36.2 pts worse
|
81.7%
38 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 63.2% · Q3 39.1% · Q4 18.4% · 4Q avg 43.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.5% |
13.2%
4.7 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 8.6% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.4% |
78.1%
14.7 pts worse
|
79.7%
16.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.1% |
22.9%
13.8 pts better
|
23.9%
14.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.6% · Expected 22.4% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (3 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Resident Assessment and Care Planning (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2025-05-19
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 2025-05-19
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-05-19
Fire Safety
Install proper backup exit lighting.
Corrected 2025-05-19
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 2025-05-19
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-05-19
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-19
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-19
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-19
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-19
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-19
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-19
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-05-19
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2025-05-19
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-19
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 2023-10-17
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-17
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-17
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-10-17
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-17
Inspection history
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-27
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-04
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-02-04
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-04
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-04
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-02-04
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-04
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 2025-02-04
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-04
Health
Post nurse staffing information every day.
Corrected 2025-02-04
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-09-26
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-11-03
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-03
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-13
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-19
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-10-19
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-10-19
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-19
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-19
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-19
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-15
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-19
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-19
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-11-03
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-19
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 2023-10-19
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-10-19
Health
Post nurse staffing information every day.
Corrected 2023-10-19
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-10-19
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-04-12
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-04-12
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 2022-04-12
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-04-12
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-12
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-04-12
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 2022-04-12
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-04-12
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2022-04-12
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-04-12
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2022-04-12
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-04-12
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-04-12
Penalties and ownership
Fine · fine $17,345
Fine
Fine · fine $116,519
Fine
Payment Denial · denial start 2023-09-08 · 56 days
56 day denial
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Nearby options
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
Concord, NC
1-star overall rating with 1-star inspections with abuse icon flag with $129,204 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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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