Kannapolis Health and Rehabilitation

Inspectors wroteBased on record review, observations, and interviews with family, staff, Nurse Practitioner, and Physician, the facility failed to provide the necessary supervision for a resident who was severely cognitively impaired, had difficulty swallowing, and was on a mechanical soft diet (foods that are naturally soft or altered [chopped, ground, mashed, or pureed] to require minimal chewing, making them safer and easier to swallow) with nectar thickened liquids (thickened consistency to slow the flow of the liquid to prevent choking and aspiration by allowing more time for the airway to close). Resident #103's family member, Family Member #1, was repeatedly observed by staff bringing the resident food items that were not consistent with his ordered diet and the facility failed to implement effective interventions to protect the resident from an avoidable accident. [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to discard expired multi-use medications on 1 of 2 medication carts reviewed (Medication Cart [DATE]) and failed to date multi-use medications upon opening, as required by manufacturer recommendations, on both medication carts reviewed (Medication Cart [DATE] and Medication Cart [DATE]). These failures have the potential to result in the administration of expired or improperly labeled medications.

Inspectors wroteBased on observation, record review, and interviews with residents and staff, the facility did not maintain a resident bed in safe working condition for 1 of 1 resident room reviewed for a safe and homelike environment on 1 of 4 halls (Resident #58). An initial observation of Resident #58's room on 03/01/2026 at 1:58PM, revealed Resident #58 was in a semi-private room and positioned in the bed near the door. Observation revealed the head of the bed was elevated in an upright position and the bed was positioned above its lowest setting. At the time of observation, the bed was unplugged. Electrical wiring was observed hanging beneath the bed. Multiple internal wires (white, blue, red, and yellow) were visible along with a gold-colored exposed wire. The exposed wiring appeared damaged and was not properly secured to the bed frame. [...]

Inspectors wroteBased on record review, observation, and interviews with resident and staff, the facility failed to ensure a resident who was dependent on staff assistance for incontinence care (Resident #18) and for changing soiled clothing (Resident #87) received assistance when needed for 2 of 11 residents reviewed for activities of daily living (Residents #18 and #87).

Inspectors wroteBased on observations, record review and resident and staff interviews, the facility failed to store a plastic syringe used for enteral water flushes (water flushes are essential to maintain gastrostomy/feeding tube patency, prevent clogging and support hydration), dry and with the plunger separated from the syringe and free from moisture for 1 of 2 residents reviewed for enteral feeding management (Resident #27). This practice had the potential for bacterial growth and contamination.

Inspectors wroteBased on observations, record review and staff and Medical Director interviews, the facility did not administer intravenous (IV) fluids (give fluids through a vein) according to physician orders for 1 of 2 residents reviewed for intravenous therapy (Resident #6).

Inspectors wroteBased on record review, observations, and Nurse Practitioner (NP), resident, and staff interviews, the facility failed to obtain a physician's order for the use of continuous oxygen for 1 of 6 residents reviewed for respiratory care (Resident #16).

Inspectors wroteBased on record review and physician, resident and staff interviews, the facility failed to administer insulin in accordance with the physician's orders for 13 out of 30 days in June 2025 for 1 of 3 residents reviewed for significant medication error (Resident #33).

Inspectors wroteBased on record reviews and interviews with Responsible Party (RP), residents, and staff, the facility failed to provide the resident and RP with a written notice of transfer including the reason for the hospital transfer for 4 of 4 residents reviewed for hospitalization (Residents #33, #53, #69 and #31).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to post the daily nurse staffing sheet daily for 1 out of 5 days observed (3/1/26). The facility also failed to post accurate daily staffing information as compared to the daily staffing schedules for licensed and unlicensed nursing staff for 22 out of 28 days reviewed (2/1/26, 2/2/26, 2/3/26, 2/4/26, 2/5/26, 2/6/26, 2/7/26, 2/9/26, 2/10/26, 2/11/26, 2/12/26, 2/13/26, 2/14/26, 2/15/26, 2/18/26, 2/19/26, 2/20/26, 2/24/26, 2/25/26, 2/26/26, 2/27/26, and 2/28/26).

Inspectors wroteBased on record reviews and Resident Representative (RR), resident and staff interviews, the facility failed to indicate if grievances had been resolved, how the results were communicated to the complainant, when the results of the grievances had been provided to the complainant and also failed to provide a written grievance response summary for 3 of 3 residents reviewed for grievances (Residents #52, #69 and #39).

Inspectors wroteBased on record reviews, and Nurse Practitioner (NP), Physician, Pharmacist, Endocrinologist, and staff interviews, the facility failed to prevent a significant medication error related to hydrocortisone prescribed for Resident #137 (hydrocortisone tablets are a steroid medication that works by decreasing inflammation, slowing down an overactive immune system or replacing the cortisol hormone that helps the body respond to stress) when Resident #137 missed a dose of hydrocortisone on (8/29/24), received the wrong dose of hydrocortisone for two days (8/30/24 and 8/31/24) and then the medication was abruptly stopped. Abrupt cessation of hydrocortisone for adrenal insufficiency can cause an adrenal crisis, where the body experiences a sudden drop in cortisol levels and can lead to life-threatening complications such as low blood pressure. [...]

Inspectors wroteBased on record review, and physician and staff interviews, the facility failed to notify the Physician when a prescribed dose of hydrocortisone was not administered for 1 of 1 resident reviewed for notification (Resident #137).

Inspectors wroteBased on record review, and Responsible Party and staff interviews the facility failed to protect the private health information of 1 of 1 resident (Resident #189) when her discharge summary and medication list was sent home with another resident. A reasonable person would not want their private medical information shared with another resident.

Inspectors wroteBased on staff interviews and record review, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of swallowing for 1 of 4 residents (Resident #75) reviewed for MDS accuracy.

Inspectors wroteBased on record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to transcribe orders for inserting a peripheral intravenous (IV) line, 0.9% normal saline (NS) (water and salt) solution, and flushes (solution that's injected into an IV line to clean it and prevent blockages) for a midline (a type of peripheral IV that is longer than a peripheral IV). This was for 1 of 1 resident (Resident #75) reviewed for IV fluids.

Inspectors wroteBased on record review, and staff and Responsible Party interviews, the facility failed to send 2 of 9 residents (Resident # 188 and Resident # 189) with a list of their ordered medications and Discharge Summary when they were discharged from the facility on 7/26/2024. Resident #188 was discharged on 7/26/2024 with Resident #189's Discharge Summary and Medication List. Resident #188 did not receive the correct Discharge Summary and Medication List until 7/29/2024. Resident #189 was discharged without a Discharge Summary and Medication List on 7/26/2024 and the Family Member returned to the facility on 7/26/2024 to obtain the Discharge Summary and Medication List.

Inspectors wroteBased on record review, and Nurse Practitioner (NP) and staff interviews the facility failed to provide 1 of 1 resident (Resident #190) with a Continuous Positive Airway Pressure (CPAP) machine (a CPAP machine provides constant and steady air pressure to help a resident breath while asleep) reviewed for respiratory services.

Inspectors wroteBased on record review, and Consultant Pharmacist, and Director of Nursing interviews the Consultant Pharmacist failed to recognize a medication error when the facility failed to follow admission orders for hydrocortisone used for adrenal insufficiency. This was for 1 of 9 residents reviewed for medication errors (Resident #137).

Inspectors wroteBased on record review, and Nurse Practitioner and staff interviews, the facility failed to prevent Resident #27 from receiving an extra dose of Lyrica (a medication used to treat nerve and muscle pain). This was for 1 of 9 residents whose medications were reviewed.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to post accurate Registered Nurse (RN) hours for 3 of 94 days reviewed for posted nurse staffing (11/23/24, 1/06/25 and 1/07/25).

Inspectors wroteBased on record reviews, observations, resident and staff interviews, the facility failed to maintain a resident's dignity when a Physical Therapist Assistant used profanity directed towards 1 of 3 residents reviewed for dignity (Resident #205).

Inspectors wroteBased on record reviews, observations, resident and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of pain medication for 1 of 3 residents reviewed for abuse (Resident #201).

Inspectors wroteBased on record review, and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for the presence and frequency of wandering behaviors (Resident #11).

Inspectors wroteBased on record review, observations, staff, and resident interview the facility failed to prevent 1 of 1 resident (Resident #11) from having two unsupervised exits from the facility, both of which occurred on 09/09/23.

Inspectors wroteBased on resident observation, record review, and interviews with the nursing staff, Nurse Practitioner (NP), and Medical Director, the facility failed to administer pain medication prior to completing 50 wound dressing changes during the previous 34 days for a resident with a Stage 4 pressure ulcer and severe cognitive impairment. This occurred for 1 of 2 residents (Resident #16) reviewed for pressure ulcers. Resident #16's Stage 4 pressure ulcer on her left heel required scheduled wound dressing changes; the frequency of these dressing changes increased from once daily to twice a day on 6/22/23. At that time, Resident #16 had an order for an opioid pain medication to be administered twice daily. [...]

Inspectors wroteBased on observations, resident and staff interviews, and record reviews, the facility failed to allow residents who were assessed to be safe smokers the ability to smoke independently per their individual preference for 2 of 4 residents (Resident #46 and #31) reviewed for smoking. Resident #46 verbalized this practice resulted in his feelings of being treated like a child and a prisoner.

Inspectors wroteBased on record review and staff interviews the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) form, CMS-10055 form, to 2 of 3 residents (Resident #193 and Resident #195) reviewed for beneficiary notification.

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to provide 4 dependent residents nail care (Residents #9, #11, #52, and #70) and to provide 3 residents hair washing (Residents #11, #52, and #70) for 4 of 6 residents reviewed for activities of daily living.

Inspectors wroteBased on observation, staff and Medical Director interviews, and record reviews, the facility failed to identify the need to clarify a physician's medication order for the administration of two rapid-acting insulins to be given within 30 minutes of each other at mealtime three times daily. This duplication resulted in both rapid-acting insulins being administered on 17 occasions to 1 of 5 residents (Resident #66) reviewed for unnecessary medications.

Inspectors wroteBased on record reviews and staff interviews, , the facility failed to include documentation in the medical record of education regarding the benefits and potential side effects of the Influenza and Pneumococcal immunization, and if residents received the Influenza or Pneumococcal immunization or did not receive the Influenza Pneumococcal immunization due to medical contraindication or refusal for 4 of 5 residents reviewed for infection control (Resident #66, #19, #143, and #142).

Inspectors wroteBased on record reviews, physician, and staff interviews, the facility failed to notify the physician of blood glucose results greater than 450 (normal range 80-120) for 1 of 1 resident reviewed for notification (Resident #19).

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to provide pressure relief as ordered to prevent pressure ulcer of both heels (Resident #70) for 1 of 2 residents reviewed for pressure ulcer.

Inspectors wroteBased on record review, observations and staff interviews the facility failed to prevent 1 of 5 residents (Resident #11) from leaving the facility and found in front of the building without staff supervision.

Inspectors wroteBased on record reviews, resident, and staff interviews, the facility failed to provide routine medications for 1 of 8 residents reviewed for medication administration (Resident #19).

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 27 opportunities, resulting in a medication error rate of 7.4% for 2 of 7 residents (Resident #9 and Resident #66) observed during the medication administration observation.

Inspectors wroteBased on record review and staff interviews the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions put into place following the 3/17/2022 recertification and complaint investigation survey. The facility had deficiencies previously cited in the areas of activities of daily living provided to dependent residents (F677), pharmacy services (F755), and infection prevention and control (F880). These deficiencies were cited again during the facility's current recertification and complaint investigation survey of 8/10/2023. The continued failure of the facility during the previous federal survey of record shows a pattern of the facility's inability to sustain an effective QAA Program.

Inspectors wroteBased on observations, staff interviews, and record review, the facility staff failed to clean and disinfect a blood glucose meter (glucometer) dedicated for individual-resident use in accordance with the manufacturer of the disinfectant wipes and as indicated by the facility's policy to protect against cross-contamination from contact with other meters or equipment. This was observed for 2 out of 3 residents (Resident #66 and Resident #48) who were observed to have a blood glucose (sugar) check performed by one of two hall nurses (Nurse #2).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to include documentation in the medical record of education regarding the benefits and potential risks associated with the COVID-19 immunization, documentation each dose of the COVID-19 vaccine admininstered, and if residents did or did not receive the COVID-19 immunization due to medical contraindication or refusal for 3 of 5 residents reviewed for infection control (Resident #19, #143, and #142).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to provide written notification to the resident's responsible party regarding bed hold when the resident was hospitalized for 2 of 2 residents reviewed for hospitalization (Resident #76 and Resident #89).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to post accurate staffing information for licensed and unlicensed nursing staff for 8 of 10 posted daily staffing forms reviewed (2/24/2023, 3/20/2023, 3/21/2023,4/5/2023, 4/6/2023, 5/20/2023, 5/21/2023, and 6/26/2023) and failed to post the daily nursing staffing sheet daily for 2 of 4 days observed (7/31/2023 and 8/3/2023).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to complete daily skilled nursing assessment for 3 of 3 residents reviewed for documentation (Resident #19, #76, and #142).