Pelican Health Randolph: Call Light Left Out of Reach - NC
The resident, identified in inspection records only as Resident #5, has a cervical spinal cord injury and quadriplegia. He cannot use his upper or lower extremities and requires maximum assistance for every activity of daily living. His call button is not the standard kind. It sits beside his head, and he activates it by pressing it with the right side of his face.
Without it, he has no way to ask for anything.
On the afternoon of September 10, a state surveyor watched a nurse aide provide catheter care to Resident #5. When the aide finished and started to leave the room, the call button was nowhere in sight. The surveyor asked whether Resident #5 had a way to call for help. The aide stopped, looked behind the nightstand, and found the button there. She placed it beside his head, watched him press it with his cheek, and checked that the call light activated in the hallway before walking out.
In an interview thirty minutes later, the aide said she did not normally work with Resident #5 but knew how his call button worked. She said she had been distracted by performing catheter care in front of a surveyor and forgot.
That was the afternoon. That evening was worse.
At 8:10 PM, while the surveyor stood in the facility lobby, a voice came from down the hall. Resident #5 was yelling for help from his room. The surveyor walked in and found the call button hanging off the right side of the bed, out of reach. A different aide, who was assigned to Resident #5 and had been transporting another resident in a wheelchair in the hallway, came in, asked what Resident #5 needed, and handed him the button. He helped remove Resident #5's dentures and confirmed the button was accessible before leaving.
That aide told inspectors he had forgotten to leave the call button because he was trying to get all his residents into bed for the night. He said he knew he would be back shortly. He said he normally remembered.
Resident #5 had already told inspectors, in an interview two days earlier, that this was not unusual. He said staff did not like to give him his call button. He said he was paralyzed from the chest down and depended entirely on staff for help.
The Director of Nursing, interviewed on September 12, said she expected staff to make sure every resident could call for assistance before leaving the room. She said both aides should have given Resident #5 his button before they left. The administrator, interviewed the same day, said the same thing.
What the inspection captured in a single day was a man who could not roll over, could not reach a phone, could not get out of bed, and could not do anything at all except wait, and hope someone remembered him before he needed something badly enough to shout.
He had to shout.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pelican Health Randolph LLC from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 18, 2026 · Our methodology
Pelican Health Randolph LLC in Charlotte, NC was cited for violations during a health inspection on September 17, 2025.
The resident, identified in inspection records only as Resident #5, has a cervical spinal cord injury and quadriplegia.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.