Pelican Health Randolph: Wound Hidden at Discharge - NC
Not in the discharge paperwork. Not in a phone call. Not anywhere.
The resident, identified in inspection records only as Resident #89, was diabetic and had been wearing an ankle brace for a fracture she'd sustained about a year earlier. The wound, a physician at the assisted living facility later told the family, was a diabetic wound. Home health services were ordered the next day to begin treating it. The family had no idea it existed until that moment.
"There was no mention of the left ankle wound in Resident #89's discharge paperwork," the family member told inspectors during an interview on September 10, 2025. "The skilled nursing facility had not been treating the wound and had not notified her that Resident #89 had developed a wound while in the facility."
The family member said she didn't know when the wound had developed. Neither, apparently, did anyone at Pelican Health.
Federal inspectors documented the deficiency following a complaint investigation completed September 17, 2025. What they found was not a complex medical mystery. It was a failure that ran through nearly every layer of the facility's clinical staff.
The wound care physician told inspectors she had never been consulted about Resident #89 at all. She had never seen her, never treated her, and the resident had never appeared on her wound care caseload. The nurse practitioner said she didn't recall any wounds or skin alterations and explained that nursing staff would have notified her of any abnormality, at which point she would have called the wound care physician. That notification apparently never came.
The Director of Rehabilitation had worked with Resident #89 on one occasion, on February 13, 2025, to adjust the ankle brace because the resident's lower extremities would periodically swell. She removed the brace that day, inspected the skin, and said it was intact. She tightened the fit and reapplied it. The resident's family had told her the woman wore the brace only occasionally, could bear full weight on both legs, and had no specific restrictions.
Eleven days later, Resident #89 left the facility with a wound the size of a fifty-cent piece on the same ankle, undocumented and untreated.
The former Director of Nursing could not be reached. Inspectors made multiple attempts and got no response. The former social worker who prepared the discharge summary said she did not remember Resident #89.
The assisted living facility's executive director told inspectors that the nurse who had admitted Resident #89 and first observed the wound was also no longer employed there and could not be contacted. The medication aide who documented the wound in a progress note on February 25, 2025, the day after admission, had likewise left the facility and was unreachable.
What remained was a paper trail that told the story in pieces. A progress note from the assisted living facility, timestamped 4:46 PM on February 25, recording that Resident #89 had arrived with an open wound on her left foot. A physician order the same day for home health to evaluate and treat a left heel wound. And a discharge summary from Pelican Health that contained no mention of any abnormal skin condition, no wound care orders, nothing.
Resident #89 stayed at the assisted living facility and received the wound care she needed from home health nurses. Whether the wound developed under the brace during her stay at Pelican Health, and how long it had been there before anyone noticed it at all, the inspection record does not say. The family member said she simply didn't know when it started.
What she did know was that she found out about it the same way the assisted living staff did: by looking.
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.
Not in the discharge paperwork.
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.