Pelican Health Randolph: Feeding Tube Care Failures - NC
Inspectors cited Pelican Health Randolph LLC under a standard requiring that feeding tubes not be used unless there is a documented medical reason and the resident has consented, and that residents who do have feeding tubes receive appropriate ongoing care. The facility fell short on both counts.
The deficiency was classified as isolated, meaning inspectors did not find it affecting residents across the board. But the severity designation they assigned — potential for more than minimal harm — reflects what is already understood about feeding tube complications in nursing home settings. Aspiration pneumonia, infections at the insertion site, tube displacement, and aspiration of formula into the lungs are among the documented risks that follow when tube feeding is not carefully managed. A resident who has a feeding tube placed without a clear medical basis, or without their agreement, faces those risks for no justified reason.
Feeding tubes in nursing homes sit at a complicated intersection of medical need, patient autonomy, and institutional convenience. For residents who cannot swallow safely, a tube can be a lifeline. But the decision to place one is supposed to belong to the resident, or when that's not possible, to whoever holds authority to make decisions on their behalf. Inspectors are trained to look at whether the medical record supports the use of the tube and whether consent was properly obtained and documented. When those elements are missing or incomplete, it signals a breakdown somewhere, either in how the clinical decision was made, how it was communicated, or how it was recorded.
The inspection report does not identify how many residents were affected or specify whether the problem was one of inadequate care, improper use, or missing consent documentation. What it establishes is that the deficiency was real enough to cite and that the facility accepted the finding.
This was one of 15 deficiencies cited during the September 17 inspection. The breadth of that list, across a single complaint-driven survey, points to systemic pressures that tend to surface across departments simultaneously: staffing, documentation, care planning, and resident rights violations rarely travel alone. Whether those other 14 citations touch on related corners of resident care is not detailed in the available inspection record.
Pelican Health Randolph reported a correction date of October 17, 2025, one month after the inspection. What that correction looks like in practice, whether it means revised protocols, retraining of staff, a review of current residents with feeding tubes, or some combination, is not described in the inspection record. Correction dates are self-reported by facilities. CMS does not independently verify that the stated fix has actually taken hold until the next survey cycle, which means a resident receiving tube feeding at Pelican Health Randolph today is relying, at least in part, on the facility's own account of what it changed.
The feeding tube citation carries a severity level of D, the lowest rung on the four-point scale that CMS uses to measure actual harm. No resident was documented as having been harmed by the deficiency. That is meaningful, but it is not reassuring in the way the designation can sometimes sound. A level D finding means inspectors caught the problem before someone was hurt, or that any harm that occurred was not detectable at the time of the survey. It does not mean the underlying conditions were minor.
For a resident in a nursing home who cannot advocate for themselves, a feeding tube placed without clear medical necessity or proper consent represents a loss of control over one of the most intimate decisions a person can face. Whether to be kept alive through artificial nutrition, and under what circumstances, is a question that belongs to the resident first. When the facility's records cannot demonstrate that the question was asked and answered properly, the resident's voice has been left out of their own care.
Inspectors were at Pelican Health Randolph because of a complaint. Whatever prompted someone to call, the feeding tube deficiency was among what they found when they arrived.
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 19, 2026 · Our methodology
Pelican Health Randolph LLC in Charlotte, NC was cited for violations during a health inspection on September 17, 2025.
The facility fell short on both counts.
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.